Provider Demographics
NPI:1912392994
Name:TAM, JERRY
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:
Last Name:TAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JERRY
Other - Middle Name:KEAOPUA
Other - Last Name:COSTA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:671 W RATTLESNAKE PL
Mailing Address - Street 2:
Mailing Address - City:CASA GRANDE
Mailing Address - State:AZ
Mailing Address - Zip Code:85122-6604
Mailing Address - Country:US
Mailing Address - Phone:808-960-5708
Mailing Address - Fax:
Practice Address - Street 1:4212 N 16TH ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-5319
Practice Address - Country:US
Practice Address - Phone:602-263-1200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-06
Last Update Date:2015-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN184402163W00000X
HIRN49694163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse