Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363L00000X | Nurse Practitioner | 2019003626 | MO |
N | 363LA2200X | Nurse Practitioner - Adult Health | 2019003626 | MO |
N | 363LG0600X | Nurse Practitioner - Gerontology | 2019003626 | MO |
N | 363LP2300X | Nurse Practitioner - Primary Care | 2019003626 | MO |
NPI | 1013475599 |
---|---|
Provider Name | Wilson Gachugu Ndungu |
First Address | Hazelwood, MO 63042-2711 |
Second Address | Hazelwood, MO 63042-2711 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 04/03/2019 |
Last Update Date | 05/11/2020 |