Provider Demographics
NPI:1407338031
Name:MOGONDO, TOM MOTARI (MSN, ARNP-PMHNP-BC)
Entity Type:Individual
Prefix:MR
First Name:TOM
Middle Name:MOTARI
Last Name:MOGONDO
Suffix:
Gender:M
Credentials:MSN, ARNP-PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14412 W 65TH TER
Mailing Address - Street 2:
Mailing Address - City:SHAWNEE
Mailing Address - State:KS
Mailing Address - Zip Code:66216-2123
Mailing Address - Country:US
Mailing Address - Phone:913-710-2373
Mailing Address - Fax:
Practice Address - Street 1:100 E EUCLID AVE
Practice Address - Street 2:STE 157
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50313-4583
Practice Address - Country:US
Practice Address - Phone:515-585-0008
Practice Address - Fax:307-215-1187
Is Sole Proprietor?:No
Enumeration Date:2018-08-30
Last Update Date:2020-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS78352363LP0808X
IAG155679363LP0808X
WY42009.1847363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health