Provider Demographics
NPI:1629174578
Name:VICARI-GREEN, TAMMY J (PA-C)
Entity Type:Individual
Prefix:
First Name:TAMMY
Middle Name:J
Last Name:VICARI-GREEN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:TAMMY
Other - Middle Name:J
Other - Last Name:VICARI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 2147
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:239-343-1614
Mailing Address - Fax:239-343-3695
Practice Address - Street 1:2776 CLEVELAND AVE
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33901-5864
Practice Address - Country:US
Practice Address - Phone:239-343-1614
Practice Address - Fax:239-343-3695
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-16
Last Update Date:2022-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN291664L163WP0809X
PAMA002095L363AM0700X
FLPA9112219363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
No163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, AdultGroup - Single Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL106153700Medicaid