NPIMap

Individual provider Active NPI

Ivan Che Ndamukong, PHD, PA-C

  • Physician Assistant
  • Portsmouth, VA
National Provider Identifier
1679234371
Registry record updated Aug 29, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Physician AssistantTaxonomy code 363A00000X
License
0110008765 Issued in VA
Practice address
1040 University Blvd Ste 205
Portsmouth, VA 23703-2650
Phone
(757) 391-7370
NPI assigned
Jan 4, 2022
Sex
Male
Sole proprietor
Yes

NPPES NPI Registry

Updated by the provider on Aug 29, 2022

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Physician Assistant 363A00000X 0110008765 VA Primary

Addresses

Primary practice location

1040 University Blvd Ste 205
Portsmouth, VA 23703-2650

Mailing address

2113 Chesterfield Loop
Chesapeake, VA 23323-6670
Phone (252) 412-9548

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in VA, NC2 enrollments
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
I20230124000977 VA Practitioner - Physician Assistant 7911378252 Reassigns benefits to 1 organization
I20251120000573 NC Practitioner - Physician Assistant 7911378252 Reassigns benefits to 1 organization

Care Compare profile

Medicare Care Compare
Specialty
Physician Assistant
Education
Other, 2022
Medicare assignment
May accept Medicare assignment
Group practices
Bon Secours Medical Group Hampton Roads Specialty Care LLCGroup PAC ID 3173955671, 197 clinicians

Practice addresses (Care Compare)

120 Health Ctr Dr
Ahoskie, NC 27910-8161
Phone (252) 332-3548

150 Kingsley LN
Norfolk, VA 23505-4602
Phone (757) 398-2673

305 Beechwood Blvd
Murfreesboro, NC 27855-1134
Phone (252) 398-3323

3636 High St
Portsmouth, VA 23707-3236
Phone (757) 398-2222

Hospital & facility affiliations

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Physician Assistant, Doctor of Philosophy

State licenses

LicenseStateTypeSpecialty
0110008765VAMDPhysician Assistant

Practice roles

OrganizationSpecialtyStatusNew patients
Bon Secours Medical Group Hampton Roads Specialty Care LLC CurrentSince Oct 17, 2022 Accepting new patients
Roanoke Chowan Community Health Center Inc CurrentSince Aug 30, 2025 Accepting new patients
Roanoke Chowan Community Health Center Inc Current Accepting new patients
Roanoke Chowan Community Health Center Inc CurrentSince Aug 30, 2025 Accepting new patients

Locations

120 Health Center Dr
Ahoskie, NC 27910
Phone (252) 209-0237

305 Beechwood Blvd
Murfreesboro, NC 27855
Phone (252) 398-3323

150 Kingsley Ln
Norfolk, VA 23505
Phone (757) 464-6944

1040 University Blvd
Ste 205
Portsmouth, VA 23703
Phone (757) 484-2272

3636 High St
Portsmouth, VA 23707
Phone (757) 398-2200

Organizations & group practices 4

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

Hospital & facility affiliations 9

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1641254400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1661731200000",
    "number": "1679234371",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2113 CHESTERFIELD LOOP",
            "city": "CHESAPEAKE",
            "state": "VA",
            "postal_code": "233236670",
            "telephone_number": "252-412-9548"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1040 UNIVERSITY BLVD STE 205",
            "city": "PORTSMOUTH",
            "state": "VA",
            "postal_code": "237032650",
            "telephone_number": "757-391-7370"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "NDAMUKONG",
        "first_name": "IVAN",
        "middle_name": "CHE",
        "credential": "PHD, PA-C",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2022-01-04",
        "last_updated": "2022-08-29",
        "certification_date": "2022-08-29",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "VA",
            "license": "0110008765",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Portsmouth, VA

Sources for this page

Verify at the official NPI Registry.