Provider Demographics
NPI:1487891776
Name:NGOUMGNA, ETIENNE T (PA-C MHS MSC)
Entity type:Individual
Prefix:MR
First Name:ETIENNE
Middle Name:T
Last Name:NGOUMGNA
Suffix:
Gender:M
Credentials:PA-C MHS MSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:821 N EUTAW ST
Mailing Address - Street 2:SUITE 103
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21201-4648
Mailing Address - Country:US
Mailing Address - Phone:410-225-8760
Mailing Address - Fax:
Practice Address - Street 1:821 N EUTAW ST
Practice Address - Street 2:SUITE 103
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-4648
Practice Address - Country:US
Practice Address - Phone:410-225-8760
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-01-08
Last Update Date:2010-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0002500363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD180910Y8SMedicare PIN
MDS589Medicare PIN