MEDICARE: FOMUNDAM NEWNTON MBUH NP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	AP142762	TX
2	363LF0000X	Family Nurse Practitioner	AP142762	TX

General Provider Information

NPI Number	:	1003464496
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	FOMUNDAM NEWNTON MBUH NP

Provider Business Mailing Address
First Line	:	PO BOX 788
Second Line	:
City	:	ALEDO
State	:	TX
Zip	:	76008-0788
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	648 E BUTLER ST
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76110-5523
Country	:	US
Telephone Number	:	817-382-0005
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/28/2019
Last Update Date	:	05/08/2026

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