Healthcare Provider Details

I. General information

NPI: 1033373352
Provider Name (Legal Business Name): DOMINIC JEROME GIALLOMBARDO MT(ASCP), RN, PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/16/2008
Last Update Date: 01/06/2021
Certification Date: 01/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

652 N OTSEGO AVE
GAYLORD MI
49735-2502
US

IV. Provider business mailing address

652 N OTSEGO AVE
GAYLORD MI
49735-2502
US

V. Phone/Fax

Practice location:
  • Phone: 989-732-3529
  • Fax: 989-732-7865
Mailing address:
  • Phone: 989-732-3529
  • Fax: 989-732-7865

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601005278
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: