Provider Demographics
NPI:1174853907
Name:KIDANE, MEAZA Z (PA-C)
Entity type:Individual
Prefix:MS
First Name:MEAZA
Middle Name:Z
Last Name:KIDANE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:MEAZA
Other - Middle Name:Z
Other - Last Name:KIDANE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:19789 MT WASATCH DR
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92508-3281
Mailing Address - Country:US
Mailing Address - Phone:951-512-9860
Mailing Address - Fax:
Practice Address - Street 1:19789 MT WASATCH DR
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92508-3281
Practice Address - Country:US
Practice Address - Phone:951-251-9860
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-29
Last Update Date:2024-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20768363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical