Provider Demographics
NPI:1013621010
Name:FOMANKA, BASIL E (NP)
Entity Type:Individual
Prefix:
First Name:BASIL
Middle Name:E
Last Name:FOMANKA
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14201 OXFORD DR
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MD
Mailing Address - Zip Code:20707-5855
Mailing Address - Country:US
Mailing Address - Phone:443-520-8138
Mailing Address - Fax:
Practice Address - Street 1:14201 OXFORD DR
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MD
Practice Address - Zip Code:20707-5855
Practice Address - Country:US
Practice Address - Phone:443-520-8138
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-13
Last Update Date:2023-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TP0016XBehavioral Health & Social Service ProvidersPsychologistPrescribing (Medical)Group - Multi-Specialty