Provider Demographics
NPI:1366543316
Name:BOGART, TAMMY V (NP)
Entity type:Individual
Prefix:MS
First Name:TAMMY
Middle Name:V
Last Name:BOGART
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:TAMMY
Other - Middle Name:V
Other - Last Name:SMALT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:PO BOX 8310
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24014-0310
Mailing Address - Country:US
Mailing Address - Phone:540-345-3556
Mailing Address - Fax:540-342-2193
Practice Address - Street 1:235 EVERGREEN AVE
Practice Address - Street 2:
Practice Address - City:APPOMATTOX
Practice Address - State:VA
Practice Address - Zip Code:24522-4501
Practice Address - Country:US
Practice Address - Phone:434-352-7420
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2022-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF302247-1363L00000X, 363LA2200X, 363LW0102X, 363LX0001X
VA0024181135363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
No363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM302247OtherLICENSE
NY01925084Medicaid
NY122862CKOtherPREFERRED CARE PROVIDER #
NM302247OtherLICENSE