Healthcare Provider Details

I. General information

NPI: 1164296398
Provider Name (Legal Business Name): AUDRA DESIREE PACKARD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/08/2023
Last Update Date: 02/14/2024
Certification Date: 02/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1555 SOQUEL DR
SANTA CRUZ CA
95065-1705
US

IV. Provider business mailing address

2760 EL CERRITO ST
SAN LUIS OBISPO CA
93401-4671
US

V. Phone/Fax

Practice location:
  • Phone: 831-462-7700
  • Fax:
Mailing address:
  • Phone: 805-781-0406
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number63854
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: