Provider Demographics
NPI:1932110673
Name:MBA, NNANNA U
Entity Type:Individual
Prefix:MR
First Name:NNANNA
Middle Name:U
Last Name:MBA
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 1:823 W MAIN ST
Mailing Address - Street 2:SUITE 5
Mailing Address - City:SUMNER
Mailing Address - State:WA
Mailing Address - Zip Code:98390-1155
Mailing Address - Country:US
Mailing Address - Phone:253-826-4554
Mailing Address - Fax:253-826-0014
Practice Address - Street 1:823 W MAIN ST
Practice Address - Street 2:SUITE 5
Practice Address - City:SUMNER
Practice Address - State:WA
Practice Address - Zip Code:98390-1155
Practice Address - Country:US
Practice Address - Phone:253-826-4554
Practice Address - Fax:253-826-0014
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5302550001Medicare ID - Type Unspecified