Provider Demographics
NPI:1134368327
Name:FOMBO, EPHRAIM TATA (PMHNP-BC)
Entity type:Individual
Prefix:MR
First Name:EPHRAIM
Middle Name:TATA
Last Name:FOMBO
Suffix:
Gender:M
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3031 W IH 10
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78201-5159
Mailing Address - Country:US
Mailing Address - Phone:210-261-1000
Mailing Address - Fax:210-731-8678
Practice Address - Street 1:3031 W IH 10
Practice Address - Street 2:ATTN: CREDENTIALING DEPT
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78201-5159
Practice Address - Country:US
Practice Address - Phone:210-261-1000
Practice Address - Fax:210-731-8678
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-11
Last Update Date:2016-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN 330129163W00000X
TXRN796897363LP0808X
TX796897163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse