Healthcare Provider Details

I. General information

NPI: 1275959868
Provider Name (Legal Business Name): PATRICK JOMO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/06/2014
Last Update Date: 03/12/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4628 CRAFTSBURY CIR
FORT WAYNE IN
46818-2063
US

IV. Provider business mailing address

4628 CRAFTSBURY CIR
FORT WAYNE IN
46818-2063
US

V. Phone/Fax

Practice location:
  • Phone: 260-418-8599
  • Fax:
Mailing address:
  • Phone: 260-418-8599
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number28165197A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: