Basic Information
| Provider Information | |||||||||
| NPI: | 1689072001 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TIMUNGWA | ||||||||
| FirstName: | BENJAMIN | ||||||||
| MiddleName: | |||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 417297 | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 022417297 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8666233869 | ||||||||
| FaxNumber: | 3027330854 | ||||||||
| Practice Location | |||||||||
| Address1: | 901 HARRY S TRUMAN DR N | ||||||||
| Address2: | |||||||||
| City: | LARGO | ||||||||
| State: | MD | ||||||||
| PostalCode: | 207745477 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2406771000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/17/2014 | ||||||||
| LastUpdateDate: | 03/31/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 03/31/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 123858 | CT | N | Nursing Service Providers | Registered Nurse | 367500000X | 95000194 | CA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367500000X | R234704 | MD | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 163W00000X | RN9333438 | FL | N | Nursing Service Providers | Registered Nurse | 163W00000X | 688397 | CA | N | Nursing Service Providers | Registered Nurse | 367500000X | 006030 | CT | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 101907 | 01 | AANA | OTHER |