Healthcare Provider Details

I. General information

NPI: 1073823027
Provider Name (Legal Business Name): DEVAN ODDMAN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DEVAN WEIDLE PA-C

II. Dates (important events)

Enumeration Date: 10/08/2010
Last Update Date: 12/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8765 AERO DR SUITE 130
SAN DIEGO CA
92123-1781
US

IV. Provider business mailing address

8765 AERO DRIVE SUITE 130
SAN DIEGO CA
92123-1767
US

V. Phone/Fax

Practice location:
  • Phone: 858-541-0181
  • Fax:
Mailing address:
  • Phone: 858-541-0181
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number0010-06631
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: