Provider Demographics
NPI:1073132692
Name:FOMUKONG, BIANCA NGWE NDESO
Entity Type:Individual
Prefix:
First Name:BIANCA
Middle Name:NGWE NDESO
Last Name:FOMUKONG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:450A SOUTH CLAIBORNE
Mailing Address - Street 2:ROOM 521
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70112
Mailing Address - Country:US
Mailing Address - Phone:832-605-1880
Mailing Address - Fax:
Practice Address - Street 1:450A SOUTH CLAIBORNE
Practice Address - Street 2:ROOM 521
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70112
Practice Address - Country:US
Practice Address - Phone:832-605-1880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-14
Last Update Date:2023-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1097681367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered