Provider Demographics
NPI:1811207632
Name:HAIMANOT, BEKELE T (PA-C)
Entity type:Individual
Prefix:MR
First Name:BEKELE
Middle Name:T
Last Name:HAIMANOT
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9528 LOS COCHES CT
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92508-6814
Mailing Address - Country:US
Mailing Address - Phone:951-640-2828
Mailing Address - Fax:
Practice Address - Street 1:9528 LOS COCHES COURT
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92508
Practice Address - Country:US
Practice Address - Phone:951-640-2828
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-14
Last Update Date:2010-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA21O33363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical