Provider Demographics
NPI:1891484101
Name:TASSOTSA NDJITSA, AUBREVILLE AGATHON
Entity Type:Individual
Prefix:
First Name:AUBREVILLE AGATHON
Middle Name:
Last Name:TASSOTSA NDJITSA
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 1:11804 CHANTILLY LN
Mailing Address - Street 2:
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20721-2131
Mailing Address - Country:US
Mailing Address - Phone:240-879-7329
Mailing Address - Fax:
Practice Address - Street 1:4130 HUNT PL NE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20019-3565
Practice Address - Country:US
Practice Address - Phone:202-388-4300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-03
Last Update Date:2023-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
172V00000X
DC251B00000X364SP0812X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172V00000XOther Service ProvidersCommunity Health WorkerGroup - Single Specialty
No364SP0812XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, CommunityGroup - Single Specialty