Provider Demographics
NPI:1407117914
Name:SANDA, NGUH
Entity Type:Individual
Prefix:
First Name:NGUH
Middle Name:
Last Name:SANDA
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 1:9100 ELDON DR
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MD
Mailing Address - Zip Code:20735-2940
Mailing Address - Country:US
Mailing Address - Phone:301-448-8102
Mailing Address - Fax:
Practice Address - Street 1:9100 ELDON DR
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:MD
Practice Address - Zip Code:20735-2940
Practice Address - Country:US
Practice Address - Phone:301-448-8102
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-31
Last Update Date:2017-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCRN1032038163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC1407117914Medicaid