Provider Demographics
NPI:1912322371
Name:TESFAYE, MEKEDESE (PA-C)
Entity Type:Individual
Prefix:
First Name:MEKEDESE
Middle Name:
Last Name:TESFAYE
Suffix:
Gender:F
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 1:3275 HARRIS RD
Mailing Address - Street 2:
Mailing Address - City:WAYCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:31503-8956
Mailing Address - Country:US
Mailing Address - Phone:912-287-5801
Mailing Address - Fax:
Practice Address - Street 1:1617 SATILLA BLVD
Practice Address - Street 2:
Practice Address - City:WAYCROSS
Practice Address - State:GA
Practice Address - Zip Code:31501-5027
Practice Address - Country:US
Practice Address - Phone:404-642-7838
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-21
Last Update Date:2014-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA006805363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical