Healthcare Provider Details

I. General information

NPI: 1700332996
Provider Name (Legal Business Name): MR. ATEMKENG FOMENGIA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2016
Last Update Date: 06/11/2026
Certification Date: 06/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

724 MAIDEN CHOICE LN STE 304
CATONSVILLE MD
21228-0003
US

IV. Provider business mailing address

612 CORPORATE WAY STE 2M
VALLEY COTTAGE NY
10989-2027
US

V. Phone/Fax

Practice location:
  • Phone: 202-719-2530
  • Fax:
Mailing address:
  • Phone: 718-362-1411
  • Fax: 718-362-1651

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA031273
License Number StateDC
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA031273
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: