Basic Information
| Provider Information | |||||||||
| NPI: | 1134405434 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TUBARO | ||||||||
| FirstName: | JACLYN | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 32569 | ||||||||
| Address2: | |||||||||
| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 379302569 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8656947725 | ||||||||
| FaxNumber: | 8656922352 | ||||||||
| Practice Location | |||||||||
| Address1: | 9430 PARK WEST BLVD STE 130 | ||||||||
| Address2: | |||||||||
| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 379234205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8656904861 | ||||||||
| FaxNumber: | 8655608525 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/31/2011 | ||||||||
| LastUpdateDate: | 09/27/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/27/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 3795 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | Q055190 | 05 | TN | MEDICAID |