MEDICARE: MISS SHARON HEADRICK P.A

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AM0700X	Medical Physician Assistant	PA15358	CA

General Provider Information

NPI Number	:	1710132642
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS SHARON HEADRICK P.A

Provider Business Mailing Address
First Line	:	5944 COURTLAND DR
Second Line	:
City	:	RIVERSIDE
State	:	CA
Zip	:	92506
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4646 BROCKTON AVE
Second Line	:	SUITE 202
City	:	RIVERSIDE
State	:	CA
Zip	:	92506-0128
Country	:	US
Telephone Number	:	951-774-2942
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/19/2008
Last Update Date	:	11/19/2008

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