Healthcare Provider Details

I. General information

NPI: 1063225142
Provider Name (Legal Business Name): BASIL TEGHEN NDUM RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/31/2025
Last Update Date: 01/31/2025
Certification Date: 01/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9105 JOUSTING LN
UPPER MARLBORO MD
20772-4388
US

IV. Provider business mailing address

3301 RICHMOND HWY
ALEXANDRIA VA
22305-3044
US

V. Phone/Fax

Practice location:
  • Phone: 240-872-6598
  • Fax:
Mailing address:
  • Phone: 240-872-6598
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WA2000X
TaxonomyAdministrator Registered Nurse
License Number0001301762
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: