Provider Demographics
NPI:1598262958
Name:PRINCEWILL, BOMA SOBRASUA (MD)
Entity Type:Individual
Prefix:
First Name:BOMA
Middle Name:SOBRASUA
Last Name:PRINCEWILL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1005 DR DB TODD JR BLVD
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37208-3501
Mailing Address - Country:US
Mailing Address - Phone:203-278-1084
Mailing Address - Fax:
Practice Address - Street 1:1005 DR DB TODD JR BLVD
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37208-3501
Practice Address - Country:US
Practice Address - Phone:615-327-6611
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-11
Last Update Date:2022-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY55036207R00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program