1124414750 NPI number — MR. COLLINS FOKUM FOMUNUNG FNP

Table of content: MR. COLLINS FOKUM FOMUNUNG FNP (NPI 1124414750)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124414750 NPI number — MR. COLLINS FOKUM FOMUNUNG FNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FOMUNUNG
Provider First Name:
COLLINS
Provider Middle Name:
FOKUM
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
FNP
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1124414750
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/05/2026
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1130 SAM NEWELL RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MATTHEWS
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28105-5039
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-900-7761
Provider Business Mailing Address Fax Number:
833-948-3597

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1130 SAM NEWELL RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MATTHEWS
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28105-5039
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-900-7761
Provider Business Practice Location Address Fax Number:
833-948-3597
Provider Enumeration Date:
04/10/2015

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  5007564 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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