Provider Demographics
NPI:1710254255
Name:LOMBARDONI, JEREMY BRIAN (CRNA)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:BRIAN
Last Name:LOMBARDONI
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:99 E STATE ST
Mailing Address - Street 2:PO BOX 1250
Mailing Address - City:GLOVERSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12078-1203
Mailing Address - Country:US
Mailing Address - Phone:518-773-5559
Mailing Address - Fax:518-773-5601
Practice Address - Street 1:99 E STATE ST
Practice Address - Street 2:
Practice Address - City:GLOVERSVILLE
Practice Address - State:NY
Practice Address - Zip Code:12078-1203
Practice Address - Country:US
Practice Address - Phone:518-773-5559
Practice Address - Fax:518-773-5601
Is Sole Proprietor?:No
Enumeration Date:2011-11-29
Last Update Date:2015-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY551272367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYJ400073716Medicare PIN