Provider Demographics
NPI:1467030833
Name:MUNTHALI, WONGANI
Entity Type:Individual
Prefix:
First Name:WONGANI
Middle Name:
Last Name:MUNTHALI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5376 S HALEYVILLE WAY
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80016-5874
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5376 S HALEYVILLE WAY
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80016-5874
Practice Address - Country:US
Practice Address - Phone:410-979-4856
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-29
Last Update Date:2021-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COF03211191363LF0000X
CO0996428363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily