Provider Demographics
NPI:1427317049
Name:MBOYA, FORTUCHANG PETER
Entity type:Individual
Prefix:
First Name:FORTUCHANG
Middle Name:PETER
Last Name:MBOYA
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 1:7777 RIVERDALE RD
Mailing Address - Street 2:APT 102
Mailing Address - City:NEW CARROLLTON
Mailing Address - State:MD
Mailing Address - Zip Code:20784-3937
Mailing Address - Country:US
Mailing Address - Phone:301-755-8689
Mailing Address - Fax:
Practice Address - Street 1:7777 RIVERDALE RD
Practice Address - Street 2:APT 102
Practice Address - City:NEW CARROLLTON
Practice Address - State:MD
Practice Address - Zip Code:20784-3937
Practice Address - Country:US
Practice Address - Phone:301-755-8689
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-16
Last Update Date:2012-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide