Provider Demographics
NPI:1750565362
Name:MOMOH, JOHN A
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:A
Last Name:MOMOH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7710 BROOKLYN BLVD #109
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55443-2966
Mailing Address - Country:US
Mailing Address - Phone:763-566-0544
Mailing Address - Fax:763-566-5577
Practice Address - Street 1:7710 BROOKLYN BLVD #109
Practice Address - Street 2:
Practice Address - City:BROOKLYN PARK
Practice Address - State:MN
Practice Address - Zip Code:55443-2966
Practice Address - Country:US
Practice Address - Phone:763-566-0544
Practice Address - Fax:763-566-5577
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-19
Last Update Date:2007-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN976943747P1801X, 374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No374U00000XNursing Service Related ProvidersHome Health Aide