Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208200000X | Surgeon | 2020014721 | MO |
Y | 208600000X | Surgeon | 2020014721 | MO |
NPI | 1003430950 |
---|---|
Provider Name | Ruben Ngnitwew Massa A |
First Address | Columbia, MO 65212-1000 |
Second Address | Columbia, MO 65212-1000 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 05/06/2020 |
Last Update Date | 05/06/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
2020014721 | MO BOARD OF HEALING ARTS (01) | MO |