Healthcare Provider Details

I. General information

NPI: 1740849397
Provider Name (Legal Business Name): JACOB CIMOLINO PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2019
Last Update Date: 06/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2635 N 7TH ST
GRAND JUNCTION CO
81501-8209
US

IV. Provider business mailing address

350 DENNISON LN
FORT BRAGG CA
95437-4048
US

V. Phone/Fax

Practice location:
  • Phone: 970-298-2273
  • Fax:
Mailing address:
  • Phone: 707-357-2892
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: