Provider Demographics
NPI:1740916907
Name:WOLDEMARIAM, MEKONNEN GASHAW
Entity type:Individual
Prefix:
First Name:MEKONNEN
Middle Name:GASHAW
Last Name:WOLDEMARIAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21512 38TH AVE W
Mailing Address - Street 2:
Mailing Address - City:MOUNTLAKE TERRACE
Mailing Address - State:WA
Mailing Address - Zip Code:98043-5722
Mailing Address - Country:US
Mailing Address - Phone:206-899-6239
Mailing Address - Fax:
Practice Address - Street 1:21512 38TH AVE W
Practice Address - Street 2:
Practice Address - City:MOUNTLAKE TERRACE
Practice Address - State:WA
Practice Address - Zip Code:98043-5722
Practice Address - Country:US
Practice Address - Phone:206-899-6239
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-28
Last Update Date:2022-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN60128714163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse