Basic Information
| Provider Information | |||||||||
| NPI: | 1215349998 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KIDANE | ||||||||
| FirstName: | EYOB | ||||||||
| MiddleName: | G | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 520 N 4TH AVE | ||||||||
| Address2: | |||||||||
| City: | PASCO | ||||||||
| State: | WA | ||||||||
| PostalCode: | 993015257 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5094168849 | ||||||||
| FaxNumber: | 5095423059 | ||||||||
| Practice Location | |||||||||
| Address1: | 7425 WRIGLEY DR | ||||||||
| Address2: | STE 100 | ||||||||
| City: | PASCO | ||||||||
| State: | WA | ||||||||
| PostalCode: | 993015292 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5094168888 | ||||||||
| FaxNumber: | 5095456842 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/29/2014 | ||||||||
| LastUpdateDate: | 08/03/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/03/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 51493 | CA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 60564696 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.