MEDICARE: MR. ATEMKENG FOMENGIA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AM0700X	Medical Physician Assistant	PA031273	DC
2	363A00000X	Physician Assistant	PA031273	DC

General Provider Information

NPI Number	:	1700332996
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. ATEMKENG FOMENGIA

Provider Business Mailing Address
First Line	:	612 CORPORATE WAY STE 2M
Second Line	:
City	:	VALLEY COTTAGE
State	:	NY
Zip	:	10989-2027
Country	:	US
Telephone Number	:	718-362-1411
Fax Number	:	718-362-1651

Provider Business Practice Location Address
First Line	:	724 MAIDEN CHOICE LN STE 304
Second Line	:
City	:	CATONSVILLE
State	:	MD
Zip	:	21228-0003
Country	:	US
Telephone Number	:	202-719-2530
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/29/2016
Last Update Date	:	06/11/2026

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Directions to “ MR. ATEMKENG FOMENGIA ” Practice Location

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