Provider Demographics
NPI:1326645961
Name:FOMBO, VICTOR N (NP)
Entity Type:Individual
Prefix:
First Name:VICTOR
Middle Name:N
Last Name:FOMBO
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9841 SHALLOW CREEK DR
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76708-6199
Mailing Address - Country:US
Mailing Address - Phone:254-495-1804
Mailing Address - Fax:
Practice Address - Street 1:1333 W MCDERMOTT DR STE 150
Practice Address - Street 2:
Practice Address - City:ALLEN
Practice Address - State:TX
Practice Address - Zip Code:75013-3088
Practice Address - Country:US
Practice Address - Phone:214-744-3361
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-06
Last Update Date:2020-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA24179378363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health