Basic Information
| Provider Information | |||||||||
| NPI: | 1588069694 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FOMENGIA | ||||||||
| FirstName: | NKANGU | ||||||||
| MiddleName: | KENNETH | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5000 COX RD | ||||||||
| Address2: | |||||||||
| City: | GLEN ALLEN | ||||||||
| State: | VA | ||||||||
| PostalCode: | 230609263 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8049685700 | ||||||||
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| Practice Location | |||||||||
| Address1: | 9000 WOODYARD RD | ||||||||
| Address2: | |||||||||
| City: | CLINTON | ||||||||
| State: | MD | ||||||||
| PostalCode: | 207354206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2405463428 | ||||||||
| FaxNumber: | 2405463429 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/31/2014 | ||||||||
| LastUpdateDate: | 06/18/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | C0006385 | MD | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.