Provider Demographics
NPI:1043562259
Name:MWANGI, SAMUEL W (NP)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:W
Last Name:MWANGI
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:333 S MADISON ST
Practice Address - Street 2:
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47305-2465
Practice Address - Country:US
Practice Address - Phone:765-286-7000
Practice Address - Fax:765-213-2769
Is Sole Proprietor?:No
Enumeration Date:2012-10-11
Last Update Date:2024-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71004221A363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300039060Medicaid
IN264431024OtherMEDICARE PTAN