Healthcare Provider Details

I. General information

NPI: 1629122767
Provider Name (Legal Business Name): TAMMY GREGERSON P.A.-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/23/2007
Last Update Date: 10/15/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5502 W BROADWAY AVE
CRYSTAL MN
55428-3508
US

IV. Provider business mailing address

5502 W BROADWAY AVE
CRYSTAL MN
55428-3508
US

V. Phone/Fax

Practice location:
  • Phone: 763-504-6500
  • Fax: 763-504-6544
Mailing address:
  • Phone: 763-504-6500
  • Fax: 763-504-6544

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number945
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: