Provider Demographics
NPI:1013000728
Name:BULLERI, TAMARA ANN (PA-C)
Entity Type:Individual
Prefix:MS
First Name:TAMARA
Middle Name:ANN
Last Name:BULLERI
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MRS
Other - First Name:TAMARA
Other - Middle Name:ANN
Other - Last Name:VIRGILIO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 64286
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21264-4286
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:600 N WOLFE ST
Practice Address - Street 2:JHOC 5-073A
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21287-0005
Practice Address - Country:US
Practice Address - Phone:410-955-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2011-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1619363A00000X
MDC03461363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant