Basic Information
| Provider Information | |||||||||
| NPI: | 1164999660 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DEBELE | ||||||||
| FirstName: | TADESSE | ||||||||
| MiddleName: | KEBEDE | ||||||||
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| Credential: | MD, MS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2202 N STOCKTON HILL RD STE 101 | ||||||||
| Address2: | |||||||||
| City: | KINGMAN | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 864014622 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9286818701 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2202 N STOCKTON HILL RD STE 101 | ||||||||
| Address2: | |||||||||
| City: | KINGMAN | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 864014622 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7028775199 | ||||||||
| FaxNumber: | 7024310265 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2018 | ||||||||
| LastUpdateDate: | 04/12/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/12/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | R7887 | AZ | N | Allopathic & Osteopathic Physicians | Family Medicine | 363A00000X | PA2058 | NV | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 390200000X | R78887 | AZ | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
ID Information
| ID | Type | State | Issuer | Description | 1164999660 | 05 | NV | MEDICAID |