Provider Demographics
NPI:1033754890
Name:FOMBON, AUGUSTINE NUBEA
Entity Type:Individual
Prefix:
First Name:AUGUSTINE
Middle Name:NUBEA
Last Name:FOMBON
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 1:601 S GREAT SOUTHWEST PKWY STE 106
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75051-1057
Mailing Address - Country:US
Mailing Address - Phone:214-718-9593
Mailing Address - Fax:
Practice Address - Street 1:601 S GREAT SOUTHWEST PKWY STE 106
Practice Address - Street 2:
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75051-1057
Practice Address - Country:US
Practice Address - Phone:214-718-9593
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-14
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy