Provider Demographics
NPI:1013771187
Name:NGWA, BLAISE
Entity Type:Individual
Prefix:
First Name:BLAISE
Middle Name:
Last Name:NGWA
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 1:3522 VISTA VERDE DR
Mailing Address - Street 2:
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20721-2889
Mailing Address - Country:US
Mailing Address - Phone:240-610-2788
Mailing Address - Fax:
Practice Address - Street 1:4530 WISCONSIN AVE NW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20016-4627
Practice Address - Country:US
Practice Address - Phone:202-450-1429
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-09
Last Update Date:2024-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator