Provider Demographics
NPI:1245525344
Name:GEBREGIORGIS, FISEHA M (PAC)
Entity type:Individual
Prefix:
First Name:FISEHA
Middle Name:M
Last Name:GEBREGIORGIS
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 74008272
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60674-8272
Mailing Address - Country:US
Mailing Address - Phone:800-598-9908
Mailing Address - Fax:702-977-1496
Practice Address - Street 1:1235 POTOMAC VALLEY RD
Practice Address - Street 2:
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20850-2757
Practice Address - Country:US
Practice Address - Phone:872-231-3162
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-16
Last Update Date:2025-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0004466363AM0700X
AZ4866363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ$$$$$$$$$OtherTRICARE