Provider Demographics
NPI:1275959868
Name:JOMO, PATRICK
Entity Type:Individual
Prefix:
First Name:PATRICK
Middle Name:
Last Name:JOMO
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 1:4628 CRAFTSBURY CIR
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46818-2063
Mailing Address - Country:US
Mailing Address - Phone:260-418-8599
Mailing Address - Fax:
Practice Address - Street 1:4628 CRAFTSBURY CIR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46818-2063
Practice Address - Country:US
Practice Address - Phone:260-418-8599
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-06
Last Update Date:2014-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28165197A367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered