Provider Demographics
NPI:1558719831
Name:TAMBORINO, MICHAEL JONATHAN (PA-C)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:JONATHAN
Last Name:TAMBORINO
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:355 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:MASSAPEQUA PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11762-1642
Mailing Address - Country:US
Mailing Address - Phone:516-592-2912
Mailing Address - Fax:
Practice Address - Street 1:355 BROADWAY
Practice Address - Street 2:
Practice Address - City:MASSAPEQUA PARK
Practice Address - State:NY
Practice Address - Zip Code:11762-1642
Practice Address - Country:US
Practice Address - Phone:516-592-2912
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-27
Last Update Date:2016-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY018951363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical