Provider Demographics
NPI:1497451314
Name:BACKEN, TAMMY RENEE (MEDICAL ASSISTANT)
Entity Type:Individual
Prefix:
First Name:TAMMY
Middle Name:RENEE
Last Name:BACKEN
Suffix:
Gender:F
Credentials:MEDICAL ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1027 S BASSWOOD CIR
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47403-5842
Mailing Address - Country:US
Mailing Address - Phone:317-903-3989
Mailing Address - Fax:
Practice Address - Street 1:510 GRAND VALLEY BLVD
Practice Address - Street 2:
Practice Address - City:MARTINSVILLE
Practice Address - State:IN
Practice Address - Zip Code:46151-5883
Practice Address - Country:US
Practice Address - Phone:765-516-6292
Practice Address - Fax:765-349-7688
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-02
Last Update Date:2023-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INE5Z6Y6E3363A00000X, 261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant