Healthcare Provider Details

I. General information

NPI: 1881824407
Provider Name (Legal Business Name): EVANS O MAGAMBO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/16/2009
Last Update Date: 07/15/2026
Certification Date: 07/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3001 SANFORD PKWY
THIEF RIVER FALLS MN
56701-2700
US

IV. Provider business mailing address

3699 CAVALLO PASS
CHASKA MN
55318-3602
US

V. Phone/Fax

Practice location:
  • Phone: 218-683-4135
  • Fax: 218-681-5614
Mailing address:
  • Phone: 612-816-8815
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number1105182A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number54956
License Number StateMN
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number54956
License Number StateMN
# 4
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number01092884A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: