Provider Demographics
NPI:1083745202
Name:ETIENNE T. NGOUMGNA
Entity Type:Organization
Organization Name:ETIENNE T. NGOUMGNA
Other - Org Name:ETIENNE T. NGOUMGNA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICIAN ASSISTANT
Authorized Official - Prefix:MR
Authorized Official - First Name:ETIENNE
Authorized Official - Middle Name:T
Authorized Official - Last Name:NGOUMGNA
Authorized Official - Suffix:
Authorized Official - Credentials:PAC MSC MHS
Authorized Official - Phone:410-368-3000
Mailing Address - Street 1:302 CASPIAN CT
Mailing Address - Street 2:
Mailing Address - City:EDGEWOOD
Mailing Address - State:MD
Mailing Address - Zip Code:21040-3612
Mailing Address - Country:US
Mailing Address - Phone:410-676-8938
Mailing Address - Fax:
Practice Address - Street 1:900 S CATON AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21229-5201
Practice Address - Country:US
Practice Address - Phone:410-368-3000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-08
Last Update Date:2008-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0002500282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital