MEDICARE: MRS. PAMELA B WAIN MPT

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	225100000X	Physical Therapist	23338	CA

General Provider Information

NPI Number	:	1760569511
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. PAMELA B WAIN MPT

Provider Business Mailing Address
First Line	:	502 LAGUNARIA LN
Second Line	:
City	:	ALAMEDA
State	:	CA
Zip	:	94502-6705
Country	:	US
Telephone Number	:	415-235-7725
Fax Number	:

Provider Business Practice Location Address
First Line	:	502 LAGUNARIA LANE
Second Line	:
City	:	ALAMEDA
State	:	CA
Zip	:	94502
Country	:	US
Telephone Number	:	415-235-7725
Fax Number	:

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

Provider Enumeration Date	:	11/01/2006
Last Update Date	:	12/04/2009

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