MEDICARE: NGONGMUN FONBISA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	171M00000X	Case Manager/Care Coordinator

General Provider Information

NPI Number	:	1356131114
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NGONGMUN FONBISA

Provider Business Mailing Address
First Line	:	512 JENNINGS MILL DR
Second Line	:
City	:	BOWIE
State	:	MD
Zip	:	20721-7240
Country	:	US
Telephone Number	:	301-302-1107
Fax Number	:

Provider Business Practice Location Address
First Line	:	512 JENNINGS MILL DR
Second Line	:
City	:	BOWIE
State	:	MD
Zip	:	20721-7240
Country	:	US
Telephone Number	:	301-302-1107
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/07/2025
Last Update Date	:	05/07/2025

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