Provider Demographics
NPI:1730590829
Name:FOMBRUN, FRED (PA-C)
Entity type:Individual
Prefix:
First Name:FRED
Middle Name:
Last Name:FOMBRUN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 WINNSBORO ST
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89074-7877
Mailing Address - Country:US
Mailing Address - Phone:862-755-9418
Mailing Address - Fax:
Practice Address - Street 1:2380 W HORIZON RIDGE PKWY STE 110
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89052-5078
Practice Address - Country:US
Practice Address - Phone:972-656-0493
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-12
Last Update Date:2014-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVPA1527363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical