Healthcare Provider Details

I. General information

NPI: 1528058898
Provider Name (Legal Business Name): PHILLIP E PENDLETON APRN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/26/2005
Last Update Date: 10/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

275 THE CROSSROADS BLVD STE A
CARMEL CA
93923
US

IV. Provider business mailing address

40 RYAN CT STE 100
MONTEREY CA
93940-7866
US

V. Phone/Fax

Practice location:
  • Phone: 831-718-9701
  • Fax: 831-886-1538
Mailing address:
  • Phone: 831-718-9701
  • Fax: 831-886-1538

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number71000962A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number14610
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4984P
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: