Basic Information
Provider Information | |||||||||
NPI: | 1134368327 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | FOMBO | ||||||||
FirstName: | EPHRAIM | ||||||||
MiddleName: | TATA | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PMHNP-BC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3031 W IH 10 | ||||||||
Address2: |   | ||||||||
City: | SAN ANTONIO | ||||||||
State: | TX | ||||||||
PostalCode: | 782015159 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2102611000 | ||||||||
FaxNumber: | 2107318678 | ||||||||
Practice Location | |||||||||
Address1: | 3031 W IH 10 | ||||||||
Address2: | ATTN: CREDENTIALING DEPT | ||||||||
City: | SAN ANTONIO | ||||||||
State: | TX | ||||||||
PostalCode: | 782015159 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2102611000 | ||||||||
FaxNumber: | 2107318678 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/11/2009 | ||||||||
LastUpdateDate: | 11/08/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | RN 330129 | OH | N |   | Nursing Service Providers | Registered Nurse |   | 363LP0808X | RN796897 | TX | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health | 163W00000X | 796897 | TX | N |   | Nursing Service Providers | Registered Nurse |   |
No ID Information.