Previous research has neglected to delineate pediatric nurse practitioner (PNP) roles in tertiary care settings (TCS). New PNP roles have developed as TCS seek cost-effective solutions to providing quality patient care and to meeting new demands for outpatient care. The authors evaluated the roles of 11 PNPs in eight specialty clinics in a large university TCS. Data were collected from various sources, including interviews, typical day information, and on-site information. Content analysis was used to analyze aspects of the PNP role that are different from other PNP clinic settings that potentially contribute to greater continuity of patient care. TCS PNPs spent less time in direct patient care and more time providing care by telephone, teaching health professionals, consulting, comforting, and counseling. PNPs performed more in-depth counseling (situational crises) and administrative tasks (follow-up, record review) and fewer primary care tasks (physical examinations) than expected. The type of clinic, average patient age, case load, and physician availability modified the PNP role. It was concluded that PNPs have a viable TCS role and contribute to patient care by performing a wide range of functions vital to a multispecialty setting.