Provider Demographics
NPI:1801852777
Name:ERVOLINA-KROLL, TAMMY BERNADETTE (RPA-C)
Entity Type:Individual
Prefix:MRS
First Name:TAMMY
Middle Name:BERNADETTE
Last Name:ERVOLINA-KROLL
Suffix:
Gender:F
Credentials:RPA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2273 W RIVER RD
Mailing Address - Street 2:
Mailing Address - City:GRAND ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:14072-2056
Mailing Address - Country:US
Mailing Address - Phone:716-774-1356
Mailing Address - Fax:
Practice Address - Street 1:1540 MAPLE RD
Practice Address - Street 2:
Practice Address - City:WILLIAMSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14221-3647
Practice Address - Country:US
Practice Address - Phone:716-580-1813
Practice Address - Fax:716-564-1134
Is Sole Proprietor?:No
Enumeration Date:2006-04-21
Last Update Date:2011-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
NY006387-1363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02073210Medicaid
NYCC0288Medicare ID - Type Unspecified
NY02073210Medicaid