Provider Demographics
NPI:1588316798
Name:LASTIMOSA, JEROME CABALHIN (CRNP-ADULT)
Entity type:Individual
Prefix:
First Name:JEROME
Middle Name:CABALHIN
Last Name:LASTIMOSA
Suffix:
Gender:M
Credentials:CRNP-ADULT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1326 GOODWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:ESSEX
Mailing Address - State:MD
Mailing Address - Zip Code:21221-6012
Mailing Address - Country:US
Mailing Address - Phone:443-935-8144
Mailing Address - Fax:
Practice Address - Street 1:1 PRICE DR
Practice Address - Street 2:
Practice Address - City:ELKTON
Practice Address - State:MD
Practice Address - Zip Code:21921-6731
Practice Address - Country:US
Practice Address - Phone:443-929-1569
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-20
Last Update Date:2022-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR184022363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology