Provider Demographics
NPI:1912218819
Name:MOMOH, PRISCILLA DOREEN (BSC)
Entity Type:Individual
Prefix:MISS
First Name:PRISCILLA
Middle Name:DOREEN
Last Name:MOMOH
Suffix:
Gender:F
Credentials:BSC
Other - Prefix:MISS
Other - First Name:PRISCILLA
Other - Middle Name:DOREEN
Other - Last Name:MOMOH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHYSICIAN ASSISTANT
Mailing Address - Street 1:2109 SARANAC ST
Mailing Address - Street 2:
Mailing Address - City:HYATTSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20783-2166
Mailing Address - Country:US
Mailing Address - Phone:202-462-7500
Mailing Address - Fax:202-462-2309
Practice Address - Street 1:1949 4TH ST NE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20002-1211
Practice Address - Country:US
Practice Address - Phone:202-462-7500
Practice Address - Fax:202-462-2309
Is Sole Proprietor?:No
Enumeration Date:2010-06-24
Last Update Date:2010-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCPA30224363AM0700X
MDC0002552363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC037410900Medicaid