Healthcare Provider Details

I. General information

NPI: 1366755530
Provider Name (Legal Business Name): NKANYEZI NGWENYAMA FERGUSON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/16/2010
Last Update Date: 09/07/2022
Certification Date: 09/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1020 HITT STREET
COLUMBIA MO
65212-0001
US

IV. Provider business mailing address

PO BOX 843966
KANSAS CITY MO
64184-3966
US

V. Phone/Fax

Practice location:
  • Phone: 573-882-4800
  • Fax: 573-884-0723
Mailing address:
  • Phone: 573-884-3300
  • Fax: 573-884-0943

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number2022031229
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number40191
License Number StateIA
# 3
Primary TaxonomyY
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number2022031229
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: