Provider Demographics
NPI:1689072001
Name:TIMUNGWA, BENJAMIN (CRNA)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:
Last Name:TIMUNGWA
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 417297
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-7297
Mailing Address - Country:US
Mailing Address - Phone:866-623-3869
Mailing Address - Fax:302-733-0854
Practice Address - Street 1:901 HARRY S TRUMAN DR N
Practice Address - Street 2:
Practice Address - City:LARGO
Practice Address - State:MD
Practice Address - Zip Code:20774-5477
Practice Address - Country:US
Practice Address - Phone:240-677-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-17
Last Update Date:2022-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT123858163W00000X
CA95000194367500000X
MDR234704367500000X
FLRN9333438163W00000X
CA688397163W00000X
CT006030367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
101907OtherAANA