Provider Demographics
NPI:1780086579
Name:PUTHEN, JOMOL SHANKO (FNP)
Entity type:Individual
Prefix:MRS
First Name:JOMOL
Middle Name:SHANKO
Last Name:PUTHEN
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:MISS
Other - First Name:JOMOL
Other - Middle Name:
Other - Last Name:GEORGE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:FNP
Mailing Address - Street 1:PO BOX 734812
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75373-4812
Mailing Address - Country:US
Mailing Address - Phone:210-358-9500
Mailing Address - Fax:210-358-9183
Practice Address - Street 1:2121 SW 36TH ST
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78237-3360
Practice Address - Country:US
Practice Address - Phone:210-358-5100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-23
Last Update Date:2024-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP125973363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily