Basic Information
| Provider Information | |||||||||
| NPI: | 1003155144 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NDEGE | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | NGAMBWA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5830 NW ZENITH DR | ||||||||
| Address2: | |||||||||
| City: | PORT SAINT LUCIE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 349863638 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7723424002 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5830 NW ZENITH DR | ||||||||
| Address2: | |||||||||
| City: | PORT SAINT LUCIE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 349863638 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7723424002 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/09/2013 | ||||||||
| LastUpdateDate: | 02/09/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | OT5339 | FL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.