Provider Demographics
NPI:1104431931
Name:AWUNG, MARTIN ANU
Entity type:Individual
Prefix:
First Name:MARTIN
Middle Name:ANU
Last Name:AWUNG
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 1:8611 LUGANO RD
Mailing Address - Street 2:
Mailing Address - City:RANDALLSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21133-4413
Mailing Address - Country:US
Mailing Address - Phone:443-255-3937
Mailing Address - Fax:410-680-6598
Practice Address - Street 1:8611 LUGANO RD
Practice Address - Street 2:
Practice Address - City:RANDALLSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21133-4413
Practice Address - Country:US
Practice Address - Phone:443-255-3937
Practice Address - Fax:410-680-6598
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-09
Last Update Date:2020-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR3496163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WH0200XNursing Service ProvidersRegistered NurseHome HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD5113504000Medicaid