Provider Demographics
NPI:1770688681
Name:TAMBASCO, JOHN ANTHONY (SLP)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:ANTHONY
Last Name:TAMBASCO
Suffix:
Gender:M
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3157 N UNIVERSITY DR
Mailing Address - Street 2:SUITE 103
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33024-2258
Mailing Address - Country:US
Mailing Address - Phone:954-442-9422
Mailing Address - Fax:954-442-9150
Practice Address - Street 1:3157 N UNIVERSITY DR
Practice Address - Street 2:SUITE 103
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33024-2258
Practice Address - Country:US
Practice Address - Phone:954-442-9422
Practice Address - Fax:954-442-9150
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA 4906235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL884371600Medicaid