Healthcare Provider Details

I. General information

NPI: 1851710594
Provider Name (Legal Business Name): PAMELA THORNBERRY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/09/2014
Last Update Date: 04/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1425 W H ST STE 200
OAKDALE CA
95361-3588
US

IV. Provider business mailing address

1425 W H ST STE 200
OAKDALE CA
95361-3588
US

V. Phone/Fax

Practice location:
  • Phone: 209-848-1005
  • Fax: 209-845-8918
Mailing address:
  • Phone: 209-848-1005
  • Fax: 209-845-8918

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA13781
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: