Provider Demographics
NPI:1124370903
Name:ANAGHO, RANDOLPH ASAMA
Entity Type:Individual
Prefix:
First Name:RANDOLPH
Middle Name:ASAMA
Last Name:ANAGHO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4709 CADDO RD,
Mailing Address - Street 2:
Mailing Address - City:COLLEGE PARK
Mailing Address - State:MD
Mailing Address - Zip Code:20740
Mailing Address - Country:US
Mailing Address - Phone:202-547-2949
Mailing Address - Fax:
Practice Address - Street 1:4709 CADDO RD,
Practice Address - Street 2:
Practice Address - City:COLLEGE PARK
Practice Address - State:MD
Practice Address - Zip Code:20740
Practice Address - Country:US
Practice Address - Phone:202-547-2949
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-04
Last Update Date:2012-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLPN1005057164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse