Provider Demographics
NPI:1306268784
Name:PENGOU FONGANG, WILFRIED
Entity type:Individual
Prefix:
First Name:WILFRIED
Middle Name:
Last Name:PENGOU FONGANG
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 1:8607 PINEY BRANCH RD APT 201
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20901-3923
Mailing Address - Country:US
Mailing Address - Phone:240-491-2452
Mailing Address - Fax:
Practice Address - Street 1:8607 PINEY BRANCH RD APT 201
Practice Address - Street 2:
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20901-3923
Practice Address - Country:US
Practice Address - Phone:240-491-2452
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-20
Last Update Date:2014-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC9744374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide