Provider Demographics
NPI:1508492190
Name:GWAN, STEPHEN SAMA JR
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:SAMA
Last Name:GWAN
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 1:7401 NEW HAMPSHIRE AVE APT 1119
Mailing Address - Street 2:
Mailing Address - City:TAKOMA PARK
Mailing Address - State:MD
Mailing Address - Zip Code:20912-6955
Mailing Address - Country:US
Mailing Address - Phone:240-460-5344
Mailing Address - Fax:
Practice Address - Street 1:7401 NEW HAMPSHIRE AVE APT 1119
Practice Address - Street 2:
Practice Address - City:TAKOMA PARK
Practice Address - State:MD
Practice Address - Zip Code:20912-6955
Practice Address - Country:US
Practice Address - Phone:240-460-5344
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-16
Last Update Date:2020-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDHHA15034374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide