# MRS. TAMMERA L PARK

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- **Entity:** Individual
- **Status:** Active
- **Sole proprietor:** No

## Provider details

- **NPI number:** 1598853129
- **Gender:** F
- **Credential:** P.A.-C

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 363A00000X | Physician Assistant | 10004691A | IN | Yes |
| 363A00000X | Physician Assistant | 2054 | CO | — |

## Other

- **Enumeration date:** 10/10/2006
- **Last updated:** 12/30/2024

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | 04020954 | — | CO |
| 01 | — | 261227YLQP | MEDICARE PTAN | CO |