MEDICARE: PATRICK JOMO

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	367500000X	Certified Registered Nurse Anesthetist	28165197A	IN

General Provider Information

NPI Number	:	1275959868
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PATRICK JOMO

Provider Business Mailing Address
First Line	:	4628 CRAFTSBURY CIR
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46818-2063
Country	:	US
Telephone Number	:	260-418-8599
Fax Number	:

Provider Business Practice Location Address
First Line	:	4628 CRAFTSBURY CIR
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46818-2063
Country	:	US
Telephone Number	:	260-418-8599
Fax Number	:

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

Provider Enumeration Date	:	03/06/2014
Last Update Date	:	03/12/2014

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