Provider Demographics
NPI:1811926546
Name:TOMBLINE, JESSICA (PA)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:TOMBLINE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 OLD COUNTRY RD
Mailing Address - Street 2:GL-71
Mailing Address - City:MINEOLA
Mailing Address - State:NY
Mailing Address - Zip Code:11501-4198
Mailing Address - Country:US
Mailing Address - Phone:516-248-3400
Mailing Address - Fax:516-248-3419
Practice Address - Street 1:380 GROVE ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11237-5503
Practice Address - Country:US
Practice Address - Phone:914-328-8077
Practice Address - Fax:914-328-6083
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-03
Last Update Date:2012-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010868363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant