Provider Demographics
NPI:1659586477
Name:MUATA, MENSA KAMAUGOGO (RSA)
Entity Type:Individual
Prefix:MR
First Name:MENSA
Middle Name:KAMAUGOGO
Last Name:MUATA
Suffix:
Gender:M
Credentials:RSA
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:731 DOUBLE JACK ST
Mailing Address - Street 2:APT F
Mailing Address - City:BOURBONNAIS
Mailing Address - State:IL
Mailing Address - Zip Code:60914-9214
Mailing Address - Country:US
Mailing Address - Phone:815-549-2302
Mailing Address - Fax:815-933-3944
Practice Address - Street 1:750 ALMAR PKWY
Practice Address - Street 2:SUITE 205
Practice Address - City:BOURBONNAIS
Practice Address - State:IL
Practice Address - Zip Code:60914-2315
Practice Address - Country:US
Practice Address - Phone:815-933-3955
Practice Address - Fax:815-933-3944
Is Sole Proprietor?:No
Enumeration Date:2007-05-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL246ZS0410X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Technologist