Provider Demographics
NPI:1932895901
Name:BESONG, AGBORTABE ENEKE
Entity Type:Individual
Prefix:
First Name:AGBORTABE
Middle Name:ENEKE
Last Name:BESONG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9105 25TH AVE
Mailing Address - Street 2:
Mailing Address - City:ADELPHI
Mailing Address - State:MD
Mailing Address - Zip Code:20783-1509
Mailing Address - Country:US
Mailing Address - Phone:301-675-6417
Mailing Address - Fax:
Practice Address - Street 1:9105 25TH AVE
Practice Address - Street 2:
Practice Address - City:ADELPHI
Practice Address - State:MD
Practice Address - Zip Code:20783-1509
Practice Address - Country:US
Practice Address - Phone:301-675-6417
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-13
Last Update Date:2023-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD172V00000X172V00000X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No172V00000XOther Service ProvidersCommunity Health Worker