Provider Demographics
NPI:1629453170
Name:IGULU LUKWANGO, AUGUSTIN
Entity Type:Individual
Prefix:
First Name:AUGUSTIN
Middle Name:
Last Name:IGULU LUKWANGO
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 1:4039 E 25TH ST
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85711-5682
Mailing Address - Country:US
Mailing Address - Phone:520-312-0747
Mailing Address - Fax:520-721-0069
Practice Address - Street 1:994 S HARRISON ROAD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85748
Practice Address - Country:US
Practice Address - Phone:520-721-1887
Practice Address - Fax:520-721-0069
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-27
Last Update Date:2015-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH4674171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor