Provider Demographics
NPI:1255656138
Name:MBIANDA, CHRISTIANE NWAWOCK (MD)
Entity Type:Individual
Prefix:
First Name:CHRISTIANE
Middle Name:NWAWOCK
Last Name:MBIANDA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:CHRISTIANE
Other - Middle Name:NWAWOCK
Other - Last Name:NGONGA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 5909
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97228-5909
Mailing Address - Country:US
Mailing Address - Phone:574-273-6767
Mailing Address - Fax:749-687-1605
Practice Address - Street 1:710 PARK PL
Practice Address - Street 2:
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46545-3519
Practice Address - Country:US
Practice Address - Phone:574-273-6787
Practice Address - Fax:574-968-7160
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-02
Last Update Date:2020-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI390200000X
IN01075238A207R00000X, 207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201291860Medicaid
IN201291860Medicaid