MEDICARE: AGENDIA MATHEW ATABONGKENG

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	374U00000X	Home Health Aide	HHA200003883	DC

General Provider Information

NPI Number	:	1720827090
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AGENDIA MATHEW ATABONGKENG

Provider Business Mailing Address
First Line	:	1405 CANADIEN GEESE CT
Second Line	:
City	:	UPPER MARLBORO
State	:	MD
Zip	:	20774-7062
Country	:	US
Telephone Number	:	202-455-7051
Fax Number	:

Provider Business Practice Location Address
First Line	:	1405 CANADIEN GEESE CT
Second Line	:
City	:	UPPER MARLBORO
State	:	MD
Zip	:	20774-7062
Country	:	US
Telephone Number	:	202-455-7051
Fax Number	:

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

Provider Enumeration Date	:	05/24/2024
Last Update Date	:	05/29/2026

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