1598853129 NPI number — MRS. TAMMERA L PARK P.A.-C

Table of content: MRS. TAMMERA L PARK P.A.-C (NPI 1598853129)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598853129 NPI number — MRS. TAMMERA L PARK P.A.-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PARK
Provider First Name:
TAMMERA
Provider Middle Name:
L
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
P.A.-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
PARK
Provider Other First Name:
TAMMERA
Provider Other Middle Name:
L
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1598853129
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/30/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4196 HIGHWAY 62 412 STE A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HARDY
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72542-8002
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1641 S US HIGHWAY 231
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CRAWFORDSVILLE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47933-9421
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
765-307-7146
Provider Business Practice Location Address Fax Number:
833-464-2510
Provider Enumeration Date:
10/10/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  2054 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: 10004691A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 04020954 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 261227YLQP . This is a "MEDICARE PTAN" identifier , issued by the state of ( CO ) . This identifiers is of the category "OTHER".




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