Basic Information
| Provider Information | |||||||||
| NPI: | 1356719199 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TAVORMINA | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | BARNDT | ||||||||
| NamePrefix: | |||||||||
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| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BARNDT | ||||||||
| OtherFirstName: | JESSICA | ||||||||
| OtherMiddleName: | LYNN | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | PA-C | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3621 S STATE ST | ||||||||
| Address2: | |||||||||
| City: | ANN ARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481081633 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7346475299 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 24 FRANK LLOYD WRIGHT DR | ||||||||
| Address2: | LOBBY A | ||||||||
| City: | ANN ARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481059484 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7349307400 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/10/2015 | ||||||||
| LastUpdateDate: | 04/16/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 5601008416 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.