Individual
MR. EPHRAIM TATA FOMBO
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
PMHNP-BC
Contact information
Practice address
3031 W IH 10, ATTN: CREDENTIALING DEPT, SAN ANTONIO, TX 78201-5159
(210) 261-1000
(210) 731-8678
Mailing address
3031 W IH 10, SAN ANTONIO, TX 78201-5159
(210) 261-1000
(210) 731-8678
Taxonomy
Speciality
Code
Description
License number
State
163W00000X
Registered Nurse
796897
TX
163W00000X
Registered Nurse
RN 330129
OH
363LP0808X
Psychiatric/Mental Health Nurse Practitioner
Primary
RN796897
TX
Other
Enumeration date
02/11/2009
Last updated
11/08/2016
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