Provider Demographics
NPI:1447765409
Name:FOMOTAR, MARCEL (CRNP-PMH)
Entity Type:Individual
Prefix:
First Name:MARCEL
Middle Name:
Last Name:FOMOTAR
Suffix:
Gender:M
Credentials:CRNP-PMH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1085 SANDERS AVE
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:CA
Mailing Address - Zip Code:93619-3935
Mailing Address - Country:US
Mailing Address - Phone:408-449-6623
Mailing Address - Fax:
Practice Address - Street 1:1085 SANDERS AVE
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:CA
Practice Address - Zip Code:93619-3935
Practice Address - Country:US
Practice Address - Phone:408-449-6623
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-12
Last Update Date:2022-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95043929163WP0808X
MDR244114363LP0808X
CA95014417363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health