Provider Demographics
NPI:1841285699
Name:BERTOLINO-THOMAS, MICHELLE LYNN (PA - C)
Entity type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:LYNN
Last Name:BERTOLINO-THOMAS
Suffix:
Gender:F
Credentials:PA - C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6226 E PIMA ST STE 100
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85712-7003
Mailing Address - Country:US
Mailing Address - Phone:520-298-7200
Mailing Address - Fax:
Practice Address - Street 1:6226 E PIMA ST STE 100
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85712-7003
Practice Address - Country:US
Practice Address - Phone:520-298-7200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-19
Last Update Date:2021-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2862363AM0700X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ044077Medicaid
AZZ109098Medicare PIN
MD229054YZUMedicare PIN
AZ044077Medicaid
0288760001Medicare NSC