Provider Demographics
NPI:1023205275
Name:DAHLBERG, AMY ELIZABETH (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:AMY
Middle Name:ELIZABETH
Last Name:DAHLBERG
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2765
Mailing Address - Street 2:
Mailing Address - City:LAKE ARROWHEAD
Mailing Address - State:CA
Mailing Address - Zip Code:92352-2765
Mailing Address - Country:US
Mailing Address - Phone:909-337-0320
Mailing Address - Fax:
Practice Address - Street 1:400 N PEPPER AVE
Practice Address - Street 2:
Practice Address - City:COLTON
Practice Address - State:CA
Practice Address - Zip Code:92324-1801
Practice Address - Country:US
Practice Address - Phone:909-354-2195
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-02
Last Update Date:2015-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA363AM0700X
CAPA19425363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant