Healthcare Provider Details

I. General information

NPI: 1154344984
Provider Name (Legal Business Name): PAMELA J WAT M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2006
Last Update Date: 01/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11370 ANDERSON ST STE 2960
LOMA LINDA CA
92354-3450
US

IV. Provider business mailing address

PO BOX 1740
LOMA LINDA CA
92354-0240
US

V. Phone/Fax

Practice location:
  • Phone: 909-558-6422
  • Fax:
Mailing address:
  • Phone: 909-558-2392
  • Fax: 909-793-2931

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZC0500X
TaxonomyCytopathology Physician
License NumberG60753
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207ZP0101X
TaxonomyAnatomic Pathology Physician
License NumberG60753
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License NumberG60753
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: