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:PO BOX 896199
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28289-6199
Mailing Address - Country:US
Mailing Address - Phone:833-936-1364
Mailing Address - Fax:605-942-7505
Practice Address - Street 1:101 WILKESBORO ST STE B
Practice Address - Street 2:
Practice Address - City:MOCKSVILLE
Practice Address - State:NC
Practice Address - Zip Code:27028-2321
Practice Address - Country:US
Practice Address - Phone:336-753-0800
Practice Address - Fax:336-753-0805
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2021-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2054363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO04020954Medicaid
CO261227YLQPOtherMEDICARE PTAN
CO261227YLQPOtherMEDICARE PTAN
COD24925Medicare UPIN