Provider Demographics
NPI:1033373352
Name:GIALLOMBARDO, DOMINIC JEROME (MT(ASCP), RN, PA-C)
Entity Type:Individual
Prefix:MR
First Name:DOMINIC
Middle Name:JEROME
Last Name:GIALLOMBARDO
Suffix:
Gender:M
Credentials:MT(ASCP), RN, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:652 N OTSEGO AVE
Mailing Address - Street 2:
Mailing Address - City:GAYLORD
Mailing Address - State:MI
Mailing Address - Zip Code:49735-2502
Mailing Address - Country:US
Mailing Address - Phone:989-732-3529
Mailing Address - Fax:989-732-7865
Practice Address - Street 1:652 N OTSEGO AVE
Practice Address - Street 2:
Practice Address - City:GAYLORD
Practice Address - State:MI
Practice Address - Zip Code:49735-2502
Practice Address - Country:US
Practice Address - Phone:989-732-3529
Practice Address - Fax:989-732-7865
Is Sole Proprietor?:No
Enumeration Date:2008-07-16
Last Update Date:2021-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601005278363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant