Provider Demographics
NPI:1801121348
Name:MBOMBOW, ETHEL (PA-C)
Entity type:Individual
Prefix:MRS
First Name:ETHEL
Middle Name:
Last Name:MBOMBOW
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:4967 CROOKS RD
Mailing Address - Street 2:STE 130
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48098-5801
Mailing Address - Country:US
Mailing Address - Phone:248-952-1601
Mailing Address - Fax:248-952-1614
Practice Address - Street 1:21409 KELLY RD
Practice Address - Street 2:SUITE 400
Practice Address - City:EASTPOINTE
Practice Address - State:MI
Practice Address - Zip Code:48021-3264
Practice Address - Country:US
Practice Address - Phone:586-777-0630
Practice Address - Fax:586-777-0631
Is Sole Proprietor?:No
Enumeration Date:2009-10-15
Last Update Date:2015-07-29
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MI5601005700363A00000X, 207R00000X
MI1088784207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine