Provider Demographics
NPI:1700123130
Name:AUGUSTINE, NSENGA
Entity Type:Individual
Prefix:
First Name:NSENGA
Middle Name:
Last Name:AUGUSTINE
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 1:1718 W COLTER ST
Mailing Address - Street 2:SUITE 163
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85015-2949
Mailing Address - Country:US
Mailing Address - Phone:602-321-2573
Mailing Address - Fax:
Practice Address - Street 1:1718 W COLTER ST
Practice Address - Street 2:SUITE 163
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85015-2949
Practice Address - Country:US
Practice Address - Phone:602-321-2573
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-04
Last Update Date:2013-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD06709386171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ766873Medicaid