Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207QH0002X | Family Doctor - Hospice and Palliative Medicine | 209023791 | IL |
NPI | 1588333033 |
---|---|
Provider Name | Mubangu Mado Mandamuna |
First Address | Champaign, IL 61822-1907 |
Second Address | Champaign, IL 61820-3935 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 08/09/2021 |
Last Update Date | 08/09/2021 |