Provider Demographics
NPI:1124314877
Name:ROOT, TAMMY ANN (FNP)
Entity type:Individual
Prefix:MISS
First Name:TAMMY
Middle Name:ANN
Last Name:ROOT
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:529 BRYANT AVE
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13204-2507
Mailing Address - Country:US
Mailing Address - Phone:315-475-8210
Mailing Address - Fax:
Practice Address - Street 1:750 E ADAMS ST
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13210-2342
Practice Address - Country:US
Practice Address - Phone:315-464-1800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-21
Last Update Date:2013-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF336801-1363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03497674Medicaid
NY03497674Medicaid