Provider Demographics
NPI:1952472151
Name:GROOM, TAMMI ELAINE (PA-C)
Entity Type:Individual
Prefix:
First Name:TAMMI
Middle Name:ELAINE
Last Name:GROOM
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 1:2557 MOWRY AVE STE 34
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94538-1614
Mailing Address - Country:US
Mailing Address - Phone:510-794-5320
Mailing Address - Fax:
Practice Address - Street 1:2557 MOWRY AVE STE 34
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94538-1614
Practice Address - Country:US
Practice Address - Phone:510-794-5320
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-11
Last Update Date:2019-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY020093363A00000X
CAPA13937363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00PA139370Medicaid
CAS51081Medicare UPIN