Basic Information
| Provider Information | |||||||||
| NPI: | 1710167671 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ELGERSMA | ||||||||
| FirstName: | TAMMY | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 8003 | ||||||||
| Address2: | |||||||||
| City: | APPLETON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 549128003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9208305900 | ||||||||
| FaxNumber: | 7152563079 | ||||||||
| Practice Location | |||||||||
| Address1: | 710 RIVERSIDE DR | ||||||||
| Address2: | |||||||||
| City: | WAUPACA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 549811941 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7152563000 | ||||||||
| FaxNumber: | 7152563079 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/08/2007 | ||||||||
| LastUpdateDate: | 05/20/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/20/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 2211-023 | WI | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 1710167671 | 05 | WI | MEDICAID |