Provider Demographics
NPI:1992381024
Name:AYUKETAH, MYLES
Entity Type:Individual
Prefix:
First Name:MYLES
Middle Name:
Last Name:AYUKETAH
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 1:8907 TONBRIDGE TER
Mailing Address - Street 2:
Mailing Address - City:HYATTSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20783-2051
Mailing Address - Country:US
Mailing Address - Phone:202-560-1140
Mailing Address - Fax:
Practice Address - Street 1:8907 TONBRIDGE TER
Practice Address - Street 2:
Practice Address - City:HYATTSVILLE
Practice Address - State:MD
Practice Address - Zip Code:20783-2051
Practice Address - Country:US
Practice Address - Phone:202-560-1140
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-19
Last Update Date:2021-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDA00183392Medicaid