Healthcare Provider Details

I. General information

NPI: 1265920680
Provider Name (Legal Business Name): EDITH NYAKAANA NYANGOMA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/01/2018
Last Update Date: 08/26/2026
Certification Date: 08/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

420 DELAWARE ST SE
MINNEAPOLIS MN
55455-0341
US

IV. Provider business mailing address

420 DELAWARE ST SE MMC 250
MINNEAPOLIS MN
55545
US

V. Phone/Fax

Practice location:
  • Phone: 612-624-9996
  • Fax:
Mailing address:
  • Phone: 612-624-9996
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number68672
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: