Healthcare Provider Details

I. General information

NPI: 1821403254
Provider Name (Legal Business Name): SANDRINE FANGA PHYSICIAN ASSISTANT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2014
Last Update Date: 03/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8118 GOOD LUCK RD
LANHAM MD
20706-3574
US

IV. Provider business mailing address

9503 SAINT ANNES CT
LANHAM MD
20706-3632
US

V. Phone/Fax

Practice location:
  • Phone: 301-552-8130
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberC0005388
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: