Provider Demographics
NPI:1609178953
Name:NEDYALKOV, TOMO M (PAC)
Entity Type:Individual
Prefix:
First Name:TOMO
Middle Name:M
Last Name:NEDYALKOV
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12880 COMMODITY PL
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33626-3101
Mailing Address - Country:US
Mailing Address - Phone:813-343-5500
Mailing Address - Fax:813-343-5506
Practice Address - Street 1:12880 COMMODITY PL
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33626-3101
Practice Address - Country:US
Practice Address - Phone:813-343-5500
Practice Address - Fax:813-343-5506
Is Sole Proprietor?:No
Enumeration Date:2010-11-18
Last Update Date:2012-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0004360363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant