=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497596944
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CLINTONMICHEAL NKENGNTEMNGWA MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/06/2024
-----------------------------------------------------
Last Update Date | 06/30/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | MSC10 5530 1 UNIVERSITY OF NEW MEXICO
-----------------------------------------------------
City | ALBUQUERQUE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87131-9142
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-272-2269
-----------------------------------------------------
Fax | 505-272-5821
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | MSC10 5530 1 UNIVERSITY OF NEW MEXICO
-----------------------------------------------------
City | ALBUQUERQUE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87131-9142
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-272-2269
-----------------------------------------------------
Fax | 505-272-5821
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number | RS2025-0221
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------