Provider Demographics
NPI:1477555779
Name:TOBOLSKY, SHIMON (MPAS, RPA-C)
Entity Type:Individual
Prefix:
First Name:SHIMON
Middle Name:
Last Name:TOBOLSKY
Suffix:
Gender:M
Credentials:MPAS, RPA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1365 WASHINGTON AVE
Mailing Address - Street 2:STE 300
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12206-1098
Mailing Address - Country:US
Mailing Address - Phone:518-489-4704
Mailing Address - Fax:518-489-0512
Practice Address - Street 1:1365 WASHINGTON AVE
Practice Address - Street 2:STE 300
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12206-1098
Practice Address - Country:US
Practice Address - Phone:518-489-4704
Practice Address - Fax:518-489-0512
Is Sole Proprietor?:No
Enumeration Date:2005-06-01
Last Update Date:2010-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006470363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0046Medicare ID - Type Unspecified
S85135Medicare UPIN