Provider Demographics
NPI:1740012061
Name:BOBO, NICOLAS GABRIEL
Entity type:Individual
Prefix:
First Name:NICOLAS
Middle Name:GABRIEL
Last Name:BOBO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1179 E 1350 N
Mailing Address - Street 2:
Mailing Address - City:AMERICAN FORK
Mailing Address - State:UT
Mailing Address - Zip Code:84003-3516
Mailing Address - Country:US
Mailing Address - Phone:801-636-6016
Mailing Address - Fax:
Practice Address - Street 1:548 E 300 S STE 106
Practice Address - Street 2:
Practice Address - City:AMERICAN FORK
Practice Address - State:UT
Practice Address - Zip Code:84003-3845
Practice Address - Country:US
Practice Address - Phone:801-980-2566
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-15
Last Update Date:2024-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program