Provider Demographics
NPI:1598853129
Name:PARK, TAMMERA L (PA-C)
Entity type:Individual
Prefix:MRS
First Name:TAMMERA
Middle Name:L
Last Name:PARK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:TAMMERA
Other - Middle Name:L
Other - Last Name:PARK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:4196 HIGHWAY 62 412 STE A
Mailing Address - Street 2:
Mailing Address - City:HARDY
Mailing Address - State:AR
Mailing Address - Zip Code:72542-8002
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1641 S US HIGHWAY 231
Practice Address - Street 2:
Practice Address - City:CRAWFORDSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47933-9421
Practice Address - Country:US
Practice Address - Phone:765-307-7146
Practice Address - Fax:833-464-2510
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2024-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2054363A00000X
IN10004691A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO04020954Medicaid
CO261227YLQPOtherMEDICARE PTAN
CO261227YLQPOtherMEDICARE PTAN
COD24925Medicare UPIN