Basic Information
| Provider Information | |||||||||
| NPI: | 1619363405 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FOGHA | ||||||||
| FirstName: | EVAN | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 648 | ||||||||
| Address2: | |||||||||
| City: | HANOVER | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210760648 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3045984850 | ||||||||
| FaxNumber: | 3045984871 | ||||||||
| Practice Location | |||||||||
| Address1: | 455 SAINT MICHAELS DR | ||||||||
| Address2: | |||||||||
| City: | SANTA FE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 875057601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5059833361 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/08/2015 | ||||||||
| LastUpdateDate: | 12/17/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | MD2018-0085 | NM | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.