Provider Demographics
NPI:1043246036
Name:PARK, TAMMY KATHRYNE (MD)
Entity Type:Individual
Prefix:DR
First Name:TAMMY
Middle Name:KATHRYNE
Last Name:PARK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:TAMMY
Other - Middle Name:KATHRYNE
Other - Last Name:PARK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 95970
Mailing Address - Street 2:
Mailing Address - City:SOUTH JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84095-0970
Mailing Address - Country:US
Mailing Address - Phone:801-352-9500
Mailing Address - Fax:801-352-9502
Practice Address - Street 1:1200 E 3900 S
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84124-1300
Practice Address - Country:US
Practice Address - Phone:801-268-7975
Practice Address - Fax:801-270-3324
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2009-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5266933-1205207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT870306646002Medicaid
UT870306646002Medicaid
UT005549924Medicare PIN