Healthcare Provider Details

I. General information

NPI: 1104362904
Provider Name (Legal Business Name): GREAT PATOOMBAL ARNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/17/2017
Last Update Date: 04/21/2023
Certification Date: 04/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

852 QUARTZ TER
WEST PALM BEACH FL
33413-1200
US

IV. Provider business mailing address

852 QUARTZ TER
WEST PALM BEACH FL
33413-1200
US

V. Phone/Fax

Practice location:
  • Phone: 561-797-7306
  • Fax:
Mailing address:
  • Phone: 561-797-7306
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number9280339
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code364SF0001X
TaxonomyFamily Health Clinical Nurse Specialist
License Number9280339
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: