Provider Demographics
NPI:1790338028
Name:FONDENGCUP, MARTIN ASONGAKAP
Entity Type:Individual
Prefix:
First Name:MARTIN
Middle Name:ASONGAKAP
Last Name:FONDENGCUP
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 1:8012 CRADDOCK RD
Mailing Address - Street 2:
Mailing Address - City:GREENBELT
Mailing Address - State:MD
Mailing Address - Zip Code:20770-3050
Mailing Address - Country:US
Mailing Address - Phone:205-563-7647
Mailing Address - Fax:
Practice Address - Street 1:8012 CRADDOCK RD
Practice Address - Street 2:
Practice Address - City:GREENBELT
Practice Address - State:MD
Practice Address - Zip Code:20770-3050
Practice Address - Country:US
Practice Address - Phone:205-563-7647
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-16
Last Update Date:2019-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCHHA14554374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide