Provider Demographics
NPI:1710167671
Name:ELGERSMA, TAMMY S (PA)
Entity Type:Individual
Prefix:
First Name:TAMMY
Middle Name:S
Last Name:ELGERSMA
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 8003
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54912-8003
Mailing Address - Country:US
Mailing Address - Phone:920-830-5900
Mailing Address - Fax:715-256-3079
Practice Address - Street 1:710 RIVERSIDE DR
Practice Address - Street 2:
Practice Address - City:WAUPACA
Practice Address - State:WI
Practice Address - Zip Code:54981-1941
Practice Address - Country:US
Practice Address - Phone:715-256-3000
Practice Address - Fax:715-256-3079
Is Sole Proprietor?:No
Enumeration Date:2007-11-08
Last Update Date:2021-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2211-023363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1710167671Medicaid
WIP00883269Medicare Oscar/Certification
WI1710167671Medicaid
WI000018Medicare Oscar/Certification
WI2211-023OtherWISCONSIN LICENSE
WI000038Medicare Oscar/Certification