MEDICARE: MRS. ELERA YEYE NWOGU P.A

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	363AM0700X	Medical Physician Assistant	C0002905	MD
2	363AM0700X	Medical Physician Assistant	PA030294	DC

General Provider Information

NPI Number	:	1497084131
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. ELERA YEYE NWOGU P.A

Provider Business Mailing Address
First Line	:	2512 NICOL CIR
Second Line	:
City	:	MITCHELLVILLE
State	:	MD
Zip	:	20721-2955
Country	:	US
Telephone Number	:	301-925-4554
Fax Number	:

Provider Business Practice Location Address
First Line	:	7940 JOHNSON AVE
Second Line	:
City	:	GLENARDEN
State	:	MD
Zip	:	20706-1772
Country	:	US
Telephone Number	:	301-341-5450
Fax Number	:	301-341-2424

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

Provider Enumeration Date	:	12/08/2009
Last Update Date	:	12/08/2009

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