Healthcare Provider Details

I. General information

NPI: 1417537655
Provider Name (Legal Business Name): EDWIN NYAMWAYA MOGAKA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/12/2021
Last Update Date: 08/12/2024
Certification Date: 08/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 COMMUNITY DR
TOBYHANNA PA
18466-8985
US

IV. Provider business mailing address

2100 MACK BLVD FL 4
ALLENTOWN PA
18103-5622
US

V. Phone/Fax

Practice location:
  • Phone: 570-895-2300
  • Fax:
Mailing address:
  • Phone: 484-884-4500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMT223964
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD484471
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: