Provider Demographics
NPI:1518996925
Name:RODVELT-BAGCHI, TAMMY J (NP)
Entity Type:Individual
Prefix:MS
First Name:TAMMY
Middle Name:J
Last Name:RODVELT-BAGCHI
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1635 DIVISADERO STREET
Mailing Address - Street 2:SUITE 625, BOX 1821
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94143-0001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1600 DIVISADERO ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94115-3010
Practice Address - Country:US
Practice Address - Phone:415-353-7171
Practice Address - Fax:415-353-7093
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2008-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA579560363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA005795600Medicaid
CA005795600Medicare PIN
CAP38505Medicare UPIN