Provider Demographics
NPI:1750031068
Name:HAILEMARIAM, MOGES LEMMA (FNP/DNP)
Entity type:Individual
Prefix:DR
First Name:MOGES
Middle Name:LEMMA
Last Name:HAILEMARIAM
Suffix:
Gender:M
Credentials:FNP/DNP
Other - Prefix:
Other - First Name:NA
Other - Middle Name:NA
Other - Last Name:NA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:NA
Mailing Address - Street 1:1335 STANFORD AVE
Mailing Address - Street 2:
Mailing Address - City:EMERYVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:94608-2536
Mailing Address - Country:US
Mailing Address - Phone:510-647-5101
Mailing Address - Fax:
Practice Address - Street 1:1335 STANFORD AVE
Practice Address - Street 2:
Practice Address - City:EMERYVILLE
Practice Address - State:CA
Practice Address - Zip Code:94608-2536
Practice Address - Country:US
Practice Address - Phone:510-647-5101
Practice Address - Fax:510-647-5105
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-28
Last Update Date:2024-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95020486363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC6360511283OtherNATIONAL REGISTRY OF CERTIFIED MEDICAL EXAMINER