Healthcare Provider Details

I. General information

NPI: 1497700066
Provider Name (Legal Business Name): NDIKA FOMUKONG P.A.C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2006
Last Update Date: 04/10/2026
Certification Date: 04/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6470 VAN NUYS BLVD STE D
VAN NUYS CA
91401-1499
US

IV. Provider business mailing address

6470 VAN NUYS BLVD STE D
VAN NUYS CA
91401-1499
US

V. Phone/Fax

Practice location:
  • Phone: 323-733-7242
  • Fax: 310-975-1292
Mailing address:
  • Phone: 323-733-7242
  • Fax: 310-975-1292

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberNP 17180
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA17839
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: