Healthcare Provider Details

I. General information

NPI: 1912218819
Provider Name (Legal Business Name): PRISCILLA DOREEN MOMOH BSC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: PRISCILLA DOREEN MOMOH PHYSICIAN ASSISTANT

II. Dates (important events)

Enumeration Date: 06/24/2010
Last Update Date: 06/24/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1949 4TH ST NE
WASHINGTON DC
20002-1211
US

IV. Provider business mailing address

2109 SARANAC ST
HYATTSVILLE MD
20783-2166
US

V. Phone/Fax

Practice location:
  • Phone: 202-462-7500
  • Fax: 202-462-2309
Mailing address:
  • Phone: 202-462-7500
  • Fax: 202-462-2309

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA30224
License Number StateDC
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberC0002552
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: