Provider Demographics
NPI:1578555207
Name:DOMBROSKI, TINA (PAC)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:DOMBROSKI
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 472
Mailing Address - Street 2:
Mailing Address - City:LEWES
Mailing Address - State:DE
Mailing Address - Zip Code:19958-0472
Mailing Address - Country:US
Mailing Address - Phone:302-645-6698
Mailing Address - Fax:302-645-4505
Practice Address - Street 1:1309 SAVANNAH RD
Practice Address - Street 2:SUITE B
Practice Address - City:LEWES
Practice Address - State:DE
Practice Address - Zip Code:19958-1514
Practice Address - Country:US
Practice Address - Phone:302-645-6698
Practice Address - Fax:302-645-4505
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC50000405363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE1000024043Medicaid
P92610Medicare UPIN
012127R11Medicare ID - Type Unspecified