Provider Demographics
NPI:1447816590
Name:NGWESE, MBONG JERRY
Entity type:Individual
Prefix:
First Name:MBONG
Middle Name:JERRY
Last Name:NGWESE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2546 WEST BLOCH RD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85041
Mailing Address - Country:US
Mailing Address - Phone:480-233-9241
Mailing Address - Fax:602-276-5063
Practice Address - Street 1:2546 WEST BLOCH RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85041
Practice Address - Country:US
Practice Address - Phone:480-233-9241
Practice Address - Fax:602-276-5063
Is Sole Proprietor?:No
Enumeration Date:2019-05-14
Last Update Date:2019-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSports