Provider Demographics
NPI:1245860220
Name:FOMBU, SAMA MAH (NP)
Entity type:Individual
Prefix:
First Name:SAMA
Middle Name:MAH
Last Name:FOMBU
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3061 SW 160TH AVE STE 107
Mailing Address - Street 2:
Mailing Address - City:MIRAMAR
Mailing Address - State:FL
Mailing Address - Zip Code:33027-4213
Mailing Address - Country:US
Mailing Address - Phone:754-204-0952
Mailing Address - Fax:
Practice Address - Street 1:3061 SW 160TH AVE STE 107
Practice Address - Street 2:
Practice Address - City:MIRAMAR
Practice Address - State:FL
Practice Address - Zip Code:33027-4213
Practice Address - Country:US
Practice Address - Phone:754-204-0952
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-18
Last Update Date:2020-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9268150363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL9268150OtherNOT USING INSURERS