Provider Demographics
NPI:1467535898
Name:TOMKO, JACQUELINE ROSE (NP RNC MSN)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:ROSE
Last Name:TOMKO
Suffix:
Gender:F
Credentials:NP RNC MSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:11 ALVENA AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:CORTLAND
Mailing Address - State:NY
Mailing Address - Zip Code:13045
Mailing Address - Country:US
Mailing Address - Phone:607-753-7578
Mailing Address - Fax:607-758-3193
Practice Address - Street 1:11 ALVENA AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:CORTLAND
Practice Address - State:NY
Practice Address - Zip Code:13045
Practice Address - Country:US
Practice Address - Phone:607-753-7578
Practice Address - Fax:607-758-3193
Is Sole Proprietor?:No
Enumeration Date:2006-10-21
Last Update Date:2013-03-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NYF3602031207V00000X, 207VG0400X, 363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02794778Medicaid