Healthcare Provider Details

I. General information

NPI: 1679529937
Provider Name (Legal Business Name): NKANGA NKANGA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/26/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

78 CROMWELL AVE
STATEN ISLAND NY
10304-3933
US

IV. Provider business mailing address

7880 CROMWELL AVE
STATEN ISLAND NY
10304
US

V. Phone/Fax

Practice location:
  • Phone: 718-351-3388
  • Fax:
Mailing address:
  • Phone: 718-351-3388
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code173000000X
TaxonomyLegal Medicine
License Number192799
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: