Provider Demographics
NPI:1750542650
Name:PHILLIPS, TAMERA J (PT)
Entity type:Individual
Prefix:
First Name:TAMERA
Middle Name:J
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:TAMERA
Other - Middle Name:J
Other - Last Name:GAWTRY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PT
Mailing Address - Street 1:450 LAUREL ST STE B
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50314-3045
Mailing Address - Country:US
Mailing Address - Phone:515-323-6485
Mailing Address - Fax:
Practice Address - Street 1:450 LAUREL ST
Practice Address - Street 2:SUITE B
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50314-3045
Practice Address - Country:US
Practice Address - Phone:515-323-6485
Practice Address - Fax:515-323-6486
Is Sole Proprietor?:No
Enumeration Date:2008-06-23
Last Update Date:2023-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA004221225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAI19172079Medicare PIN
IAI19172Medicare PIN