Healthcare Provider Details

I. General information

NPI: 1497596944
Provider Name (Legal Business Name): CLINTONMICHEAL NKENGNTEMNGWA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2024
Last Update Date: 06/30/2025
Certification Date: 06/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

MSC10 5530 1 UNIVERSITY OF NEW MEXICO
ALBUQUERQUE NM
87131-9142
US

IV. Provider business mailing address

MSC10 5530 1 UNIVERSITY OF NEW MEXICO
ALBUQUERQUE NM
87131-9142
US

V. Phone/Fax

Practice location:
  • Phone: 505-272-2269
  • Fax: 505-272-5821
Mailing address:
  • Phone: 505-272-2269
  • Fax: 505-272-5821

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberRS2025-0221
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: