Provider Demographics
NPI:1376265454
Name:MICHOMA, CLIFF CHWEYA JR
Entity Type:Individual
Prefix:
First Name:CLIFF
Middle Name:CHWEYA
Last Name:MICHOMA
Suffix:JR
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 1:1006 WORTHINGTON DR
Mailing Address - Street 2:
Mailing Address - City:EXTON
Mailing Address - State:PA
Mailing Address - Zip Code:19341-1650
Mailing Address - Country:US
Mailing Address - Phone:610-701-1034
Mailing Address - Fax:
Practice Address - Street 1:1006 WORTHINGTON DR
Practice Address - Street 2:
Practice Address - City:EXTON
Practice Address - State:PA
Practice Address - Zip Code:19341-1650
Practice Address - Country:US
Practice Address - Phone:610-701-1034
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-14
Last Update Date:2022-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MP171W00000X
171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA979Medicaid