Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207Q00000X | Family Doctor | 49138 | CO |
Y | 207Q00000X | Family Doctor | 9632 | SD |
NPI | 1003847971 |
---|---|
Provider Name | Dr. Sherryl J. Tomboulian |
First Address | Sisseton, SD 57262-2312 |
Second Address | Sisseton, SD 57262-2312 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 06/07/2006 |
Last Update Date | 11/07/2016 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
47480777 | (05) | CO |
G97195 | (02) | CA |