Provider Demographics
NPI:1598533143
Name:DEREBE, BIRUTAWIT (PA-C)
Entity type:Individual
Prefix:
First Name:BIRUTAWIT
Middle Name:
Last Name:DEREBE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:BIRUKE
Other - Middle Name:
Other - Last Name:DEREBE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3900 W NORTHWEST HWY APT 1211
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75220-5107
Mailing Address - Country:US
Mailing Address - Phone:469-396-5297
Mailing Address - Fax:
Practice Address - Street 1:2323 N CENTRAL EXPY
Practice Address - Street 2:
Practice Address - City:RICHARDSON
Practice Address - State:TX
Practice Address - Zip Code:75080-2712
Practice Address - Country:US
Practice Address - Phone:214-453-4533
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-13
Last Update Date:2025-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X, 363A00000X
TXPA19185363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
1216882OtherNATIONAL COMMISSION ON CERTIFICATION OF PHYSICIAN ASSISTANTS (NCCPA)
TXPA19185OtherTEXAS MEDICAL BOARD