Provider Demographics
NPI:1083609077
Name:MABEN, PAMELA (MD)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:
Last Name:MABEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4911 S ARROWHEAD DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:INDEPENDENCE
Mailing Address - State:MO
Mailing Address - Zip Code:64055-7005
Mailing Address - Country:US
Mailing Address - Phone:816-795-9595
Mailing Address - Fax:816-795-1188
Practice Address - Street 1:4911 S ARROWHEAD DR
Practice Address - Street 2:SUITE 200
Practice Address - City:INDEPENDENCE
Practice Address - State:MO
Practice Address - Zip Code:64055-7005
Practice Address - Country:US
Practice Address - Phone:816-795-9595
Practice Address - Fax:816-795-1188
Is Sole Proprietor?:No
Enumeration Date:2005-09-15
Last Update Date:2016-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO107790207R00000X, 207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100151230 CMedicaid
MO208995803Medicaid
KS100151230BMedicaid
MOB68814Medicare UPIN
MO208995803Medicaid
MOP197673Medicare PIN