Individual
MR. BEREKET T WOLDEMARIAM
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PA-C
Contact information
Practice address
315 W 15TH ST, LIBERAL, KS 67901-2455
(620) 629-6477
(620) 629-6651
Mailing address
PO BOX 1215, ATTN CLINIC BILLING OFFICE, LIBERAL, KS 67905-1215
(620) 629-6638
(620) 629-6684
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
1501810
KS
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
200647940A
—
OK
05
—
201129150A
—
KS
Enumeration date
04/21/2015
Last updated
03/08/2017
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