Healthcare Provider Details

I. General information

NPI: 1730944117
Provider Name (Legal Business Name): BRIANNA K TEBO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/15/2024
Last Update Date: 08/23/2024
Certification Date: 08/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 N JAMES ST
ROME NY
13440-2844
US

IV. Provider business mailing address

245 AVERY LN
ROME NY
13441-4237
US

V. Phone/Fax

Practice location:
  • Phone: 315-338-7184
  • Fax: 315-339-1975
Mailing address:
  • Phone: 315-337-1200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number032210
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: