Provider Demographics
NPI:1629122767
Name:GREGERSON, TAMMY (PA-C)
Entity Type:Individual
Prefix:
First Name:TAMMY
Middle Name:
Last Name:GREGERSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5502 W BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL
Mailing Address - State:MN
Mailing Address - Zip Code:55428-3508
Mailing Address - Country:US
Mailing Address - Phone:763-504-6500
Mailing Address - Fax:763-504-6544
Practice Address - Street 1:5502 W BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:CRYSTAL
Practice Address - State:MN
Practice Address - Zip Code:55428-3508
Practice Address - Country:US
Practice Address - Phone:763-504-6500
Practice Address - Fax:763-504-6544
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2009-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN945363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant