Provider Demographics
NPI:1376198697
Name:MAKIEU, MOMOH
Entity Type:Individual
Prefix:
First Name:MOMOH
Middle Name:
Last Name:MAKIEU
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 1:9423 HORIZON RUN RD
Mailing Address - Street 2:
Mailing Address - City:GAITHERSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20886-0493
Mailing Address - Country:US
Mailing Address - Phone:240-688-3761
Mailing Address - Fax:
Practice Address - Street 1:13994 BALTIMORE AVE STE 102
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MD
Practice Address - Zip Code:20707-5087
Practice Address - Country:US
Practice Address - Phone:301-477-2128
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-04
Last Update Date:2019-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR198342363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty