Provider Demographics
NPI:1356719199
Name:TAVORMINA, JESSICA BARNDT (PA-C)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:BARNDT
Last Name:TAVORMINA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:LYNN
Other - Last Name:BARNDT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:3621 S STATE ST
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48108-1633
Mailing Address - Country:US
Mailing Address - Phone:734-647-5299
Mailing Address - Fax:
Practice Address - Street 1:24 FRANK LLOYD WRIGHT DR
Practice Address - Street 2:LOBBY A
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48105-9484
Practice Address - Country:US
Practice Address - Phone:734-930-7400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-10
Last Update Date:2019-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601008416363A00000X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant