Healthcare Provider Details

I. General information

NPI: 1548454101
Provider Name (Legal Business Name): TAMMY NADINE O'NEILL PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2007
Last Update Date: 08/02/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

152 PIONEER LN SUITE A
BISHOP CA
93514-2563
US

IV. Provider business mailing address

152 PIONEER LN D
BISHOP CA
93514-2563
US

V. Phone/Fax

Practice location:
  • Phone: 760-873-2506
  • Fax:
Mailing address:
  • Phone: 760-872-1606
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA23196
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA10005256
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: