Provider Demographics
NPI:1043741531
Name:PETERS, PAMELA NICOLE
Entity Type:Individual
Prefix:MS
First Name:PAMELA
Middle Name:NICOLE
Last Name:PETERS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 16TH ST FL 7
Mailing Address - Street 2:BOX 0132
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94158-2545
Mailing Address - Country:US
Mailing Address - Phone:415-476-5192
Mailing Address - Fax:415-475-1811
Practice Address - Street 1:1001 POTRERO AVE # 6D
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94110-3518
Practice Address - Country:US
Practice Address - Phone:415-206-4069
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-25
Last Update Date:2018-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA158390207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARES000Medicare UPIN