Provider Demographics
NPI:1427321900
Name:MWANGI, EDWIN WAHOME (PA)
Entity type:Individual
Prefix:
First Name:EDWIN
Middle Name:WAHOME
Last Name:MWANGI
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:3105 MCCLELLAND BLVD
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64804-1640
Mailing Address - Country:US
Mailing Address - Phone:417-781-2807
Mailing Address - Fax:417-781-3309
Practice Address - Street 1:3105 MCCLELLAND BLVD
Practice Address - Street 2:
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64804-1640
Practice Address - Country:US
Practice Address - Phone:417-781-2807
Practice Address - Fax:417-781-3309
Is Sole Proprietor?:No
Enumeration Date:2012-02-15
Last Update Date:2018-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012004801207XX0005X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine