Healthcare Provider Details

I. General information

NPI: 1215956214
Provider Name (Legal Business Name): TAMRAH MILLER TENHAEFF PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2006
Last Update Date: 07/13/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

975 S FAIRMONT AVE
LODI CA
95240-5118
US

IV. Provider business mailing address

216 NUNZIA CT
ROSEVILLE CA
95661-3979
US

V. Phone/Fax

Practice location:
  • Phone: 209-339-7575
  • Fax:
Mailing address:
  • Phone: 717-471-8496
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA18020
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: