Provider Demographics
NPI:1740819622
Name:AGWO, GODSON MBAH
Entity type:Individual
Prefix:
First Name:GODSON
Middle Name:MBAH
Last Name:AGWO
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 1:3301 DUBOIS PL SE
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20019-2479
Mailing Address - Country:US
Mailing Address - Phone:202-378-3083
Mailing Address - Fax:
Practice Address - Street 1:3301 DUBOIS PL SE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20019-2479
Practice Address - Country:US
Practice Address - Phone:202-378-3083
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-03
Last Update Date:2020-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCHHA15213374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide