Healthcare Provider Details

I. General information

NPI: 1306151675
Provider Name (Legal Business Name): ANNE ENANGA LIWONJO M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/11/2010
Last Update Date: 09/29/2020
Certification Date: 09/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 HEWITT BLVD
RED WING MN
55066-2848
US

IV. Provider business mailing address

1386 N 10TH ST
LAKE CITY MN
55041-3313
US

V. Phone/Fax

Practice location:
  • Phone: 651-267-5000
  • Fax:
Mailing address:
  • Phone: 612-701-6252
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number60498
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036134343
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: