1639890908 NPI number — STANLEY DINGBOBGA FOMBAN APRN

Table of content: STANLEY DINGBOBGA FOMBAN APRN (NPI 1639890908)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639890908 NPI number — STANLEY DINGBOBGA FOMBAN APRN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FOMBAN
Provider First Name:
STANLEY
Provider Middle Name:
DINGBOBGA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
APRN
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:
1639890908
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/04/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2995 DREW ST FL 2
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CLEARWATER
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33759-3012
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
727-532-0002
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6901 SIMMONS LOOP FL 4
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RIVERVIEW
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33578-9498
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
813-302-8388
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/06/2022

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:  APRN11021138 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 116455200 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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