Provider Demographics
NPI:1629832266
Name:SAMBOLIN, ELEINE M
Entity Type:Individual
Prefix:
First Name:ELEINE
Middle Name:M
Last Name:SAMBOLIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:STREET 3 URBANIZACIO EL CONVENTO
Mailing Address - Street 2:A 51
Mailing Address - City:SAN GERMAN
Mailing Address - State:PR
Mailing Address - Zip Code:00683
Mailing Address - Country:US
Mailing Address - Phone:407-968-4748
Mailing Address - Fax:
Practice Address - Street 1:STREET 3 URBANIZACION EL CONVENTO
Practice Address - Street 2:
Practice Address - City:SAN GERMAN
Practice Address - State:PR
Practice Address - Zip Code:00683
Practice Address - Country:US
Practice Address - Phone:407-968-4748
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-13
Last Update Date:2024-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR2062363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical