Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207Q00000X | Family Doctor | AP142762 | TX |
Y | 363LF0000X | Nurse Practitioner - Family Medicine | AP142762 | TX |
NPI | 1003464496 |
---|---|
Provider Name | Fomundam Newnton Mbuh |
First Address | Aledo, TX 76008-0788 |
Second Address | Fort Worth, TX 76115-3655 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 28/08/2019 |
Last Update Date | 28/08/2019 |