Healthcare Provider Details

I. General information

NPI: 1669844866
Provider Name (Legal Business Name): TIMOTHY NGOGE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/27/2015
Last Update Date: 09/10/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 PROSPECT ST KOEHLER FIELDHOUSE
EAST STROUDSBURG PA
18301-4816
US

IV. Provider business mailing address

200 PROSPECT ST KOEHLER FIELDHOUSE
EAST STROUDSBURG PA
18301-4816
US

V. Phone/Fax

Practice location:
  • Phone: 201-435-5182
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: