Healthcare Provider Details

I. General information

NPI: 1760013619
Provider Name (Legal Business Name): FABRICE LIONEL POUGOUE NGOMSI
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/30/2020
Last Update Date: 01/30/2020
Certification Date: 01/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12041 DESSAU RD APT 2309
AUSTIN TX
78754-1729
US

IV. Provider business mailing address

12041 DESSAU RD APT 2309
AUSTIN TX
78754-1729
US

V. Phone/Fax

Practice location:
  • Phone: 501-650-4707
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: