Healthcare Provider Details

I. General information

NPI: 1255969143
Provider Name (Legal Business Name): AMBER RENEE DEBARGE YA ID 146968
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/28/2020
Last Update Date: 03/28/2020
Certification Date: 03/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2918 HAVASUPAI AVE
SAN DIEGO CA
92117-1641
US

IV. Provider business mailing address

2918 HAVASUPAI AVE
SAN DIEGO CA
92117-1641
US

V. Phone/Fax

Practice location:
  • Phone: 775-224-6043
  • Fax:
Mailing address:
  • Phone: 775-224-6043
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number146968
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: