Healthcare Provider Details

I. General information

NPI: 1780386391
Provider Name (Legal Business Name): MUKISA MARK NKWANGA SSENONO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2023
Last Update Date: 09/28/2026
Certification Date: 09/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2720 STONE PARK BLVD
SIOUX CITY IA
51104-3734
US

IV. Provider business mailing address

2720 STONE PARK BLVD
SIOUX CITY IA
51104-3734
US

V. Phone/Fax

Practice location:
  • Phone: 712-279-3500
  • Fax:
Mailing address:
  • Phone: 712-279-3500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD-57368
License Number StateIA
# 2
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberMD-57368
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: