1477270676 NPI number — PAMELA JENE WALLACE BACHELORS, RADT

Table of content: PAMELA JENE WALLACE BACHELORS, RADT (NPI 1477270676)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477270676 NPI number — PAMELA JENE WALLACE BACHELORS, RADT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WALLACE
Provider First Name:
PAMELA
Provider Middle Name:
JENE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
BACHELORS, RADT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MURRAY
Provider Other First Name:
PAMELA
Provider Other Middle Name:
JENE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
NONE
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1477270676
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/27/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1331 W AVENUE J STE 103
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LANCASTER
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93534-2946
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
661-579-3191
Provider Business Mailing Address Fax Number:
661-522-3130

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1331 W AVENUE J STE 103
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LANCASTER
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93534-2946
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
661-579-3191
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/27/2022

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YS0200X , with the licence number:  R1465460422 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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