Provider Demographics
NPI:1053938134
Name:TATOMIROVICH, NICOLE M (PA-C)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:M
Last Name:TATOMIROVICH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 NEW HAMPSHIRE AVE STE 2
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:NH
Mailing Address - Zip Code:03801-2864
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2223 NILES CORTLAND RD SE
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:OH
Practice Address - Zip Code:44484-3043
Practice Address - Country:US
Practice Address - Phone:330-965-8760
Practice Address - Fax:330-469-9706
Is Sole Proprietor?:No
Enumeration Date:2020-07-06
Last Update Date:2024-08-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OH50.006478RX363A00000X
PAMA061723363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant