Basic Information
| Provider Information | |||||||||
| NPI: | 1063029957 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KEBEDE | ||||||||
| FirstName: | DESTA | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 333 N SUMMIT ST FL 15 | ||||||||
| Address2: | |||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436042615 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8004271902 | ||||||||
| FaxNumber: | 8005645952 | ||||||||
| Practice Location | |||||||||
| Address1: | 3417 CONCORD RD STE C | ||||||||
| Address2: | |||||||||
| City: | YORK | ||||||||
| State: | PA | ||||||||
| PostalCode: | 174029001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7178401002 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/25/2020 | ||||||||
| LastUpdateDate: | 09/25/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/25/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | SP022290 | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | SP022290 | 01 | PA | NP LICENSE | OTHER |