Basic Information
| Provider Information | |||||||||
| NPI: | 1194790816 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROMANO | ||||||||
| FirstName: | JERALYN | ||||||||
| MiddleName: | GAMBONE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GAMBONE | ||||||||
| OtherFirstName: | JERALYN | ||||||||
| OtherMiddleName: | MARIA | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PA C | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 100 MEDICAL CAMPUS DR | ||||||||
| Address2: | |||||||||
| City: | LANSDALE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 194461259 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2153682100 | ||||||||
| FaxNumber: | 2153614414 | ||||||||
| Practice Location | |||||||||
| Address1: | 3839 KRATZ RD | ||||||||
| Address2: | |||||||||
| City: | COLLEGEVILLE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 194261030 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6104894878 | ||||||||
| FaxNumber: | 6104894878 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/17/2006 | ||||||||
| LastUpdateDate: | 02/08/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | MA003042L | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.