Basic Information
Provider Information | |||||||||
NPI: | 1396768545 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BAMBULAS | ||||||||
FirstName: | TAMMALYNN | ||||||||
MiddleName: | A. | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | CNM | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | HANSEN-GADDAM | ||||||||
OtherFirstName: | TAMMALYNN | ||||||||
OtherMiddleName: | ANNETTE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 2929 E THOMAS RD | ||||||||
Address2: |   | ||||||||
City: | PHOENIX | ||||||||
State: | AZ | ||||||||
PostalCode: | 850168034 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6024705000 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2601 E ROOSEVELT ST | ||||||||
Address2: |   | ||||||||
City: | PHOENIX | ||||||||
State: | AZ | ||||||||
PostalCode: | 850084973 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6023445119 | ||||||||
FaxNumber: | 6023445894 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/26/2006 | ||||||||
LastUpdateDate: | 02/27/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367A00000X | 079701 | AZ | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife |   |
ID Information
ID | Type | State | Issuer | Description | 419582 | 05 | AZ |   | MEDICAID |