Provider Demographics
NPI:1124616602
Name:TITO, TOBIN JACOB (AGPCNP-BC)
Entity type:Individual
Prefix:MR
First Name:TOBIN
Middle Name:JACOB
Last Name:TITO
Suffix:
Gender:M
Credentials:AGPCNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1004 CRYSTAL CT
Mailing Address - Street 2:
Mailing Address - City:GLENVIEW
Mailing Address - State:IL
Mailing Address - Zip Code:60025-2682
Mailing Address - Country:US
Mailing Address - Phone:847-431-3838
Mailing Address - Fax:
Practice Address - Street 1:6308 8TH AVE
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53143-5031
Practice Address - Country:US
Practice Address - Phone:847-431-3838
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-09
Last Update Date:2021-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.021978363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology