Provider Demographics
NPI:1881261584
Name:TEWELDEBRAHAN, HABTOM LEGESE
Entity type:Individual
Prefix:
First Name:HABTOM
Middle Name:LEGESE
Last Name:TEWELDEBRAHAN
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 1:2727 LBJ FWY STE 326
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75234-7478
Mailing Address - Country:US
Mailing Address - Phone:214-935-5791
Mailing Address - Fax:214-935-5717
Practice Address - Street 1:2727 LBJ FWY STE 326
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75234-7478
Practice Address - Country:US
Practice Address - Phone:214-935-5791
Practice Address - Fax:214-935-5717
Is Sole Proprietor?:No
Enumeration Date:2021-06-10
Last Update Date:2021-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP141274363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily