Soumana Djibo

Primary specialty

Family Nurse PractitionerTaxonomy code 363LF0000X

License

AP141893 Issued in TX

Practice address

855 Davis Blvd
Southlake, TX 76092-8244

Phone

(817) 912-1771

NPI assigned

Nov 13, 2021

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Other identifiers 1

Electronic endpoints 1

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Eligible to order & refer

• Part B services: No
• Medical equipment: Yes
• Home health: No
• Power mobility devices: Yes
• Hospice: No

Green means eligible to order or refer.

Medicare enrollment (NPD)

Enrolled

Credentials

Nurse Practitioner

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1636761600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1667174400000",
    "number": "1760148753",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3402 ROSEMEAD DR",
            "city": "ARLINGTON",
            "state": "TX",
            "postal_code": "760143557"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "855 DAVIS BLVD",
            "city": "SOUTHLAKE",
            "state": "TX",
            "postal_code": "760928244",
            "telephone_number": "817-912-1771"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "DJIBO",
        "first_name": "SOUMANA",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2021-11-13",
        "last_updated": "2022-10-31",
        "certification_date": "2022-10-31",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363LF0000X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner, Family",
            "state": "TX",
            "license": "AP141893",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1760148753",
            "state": "TX"
        }
    ],
    "endpoints": [
        {
            "endpointType": "SOAP",
            "endpointTypeDescription": "SOAP URL",
            "endpoint": "djibo34@gmail.com",
            "affiliation": "N",
            "endpointDescription": "Modern Medical House Calls",
            "use": "HIE",
            "useDescription": "Health Information Exchange (HIE)",
            "contentType": "CSV",
            "contentTypeDescription": "CSV",
            "address_1": "855 Davis Blvd",
            "city": "Southlake",
            "state": "TX",
            "country_code": "US",
            "postal_code": "760928244",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

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• Family Nurse Practitioner in Southlake, TX
• Providers in Southlake, TX by specialty
• Family Nurse Practitioner in Texas

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 31, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.