Provider Demographics
NPI:1174204515
Name:KOMBATE, PATHKONN
Entity type:Individual
Prefix:MR
First Name:PATHKONN
Middle Name:
Last Name:KOMBATE
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 1:12702 CHERRYWOOD LN
Mailing Address - Street 2:
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20715-1642
Mailing Address - Country:US
Mailing Address - Phone:217-331-8401
Mailing Address - Fax:
Practice Address - Street 1:12702 CHERRYWOOD LN
Practice Address - Street 2:
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20715-1642
Practice Address - Country:US
Practice Address - Phone:217-331-8401
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-27
Last Update Date:2023-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No172V00000XOther Service ProvidersCommunity Health Worker