Provider Demographics
NPI:1164296398
Name:PACKARD, AUDRA DESIREE
Entity Type:Individual
Prefix:
First Name:AUDRA
Middle Name:DESIREE
Last Name:PACKARD
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 1:2760 EL CERRITO ST
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-4671
Mailing Address - Country:US
Mailing Address - Phone:805-781-0406
Mailing Address - Fax:
Practice Address - Street 1:1555 SOQUEL DR
Practice Address - Street 2:
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95065-1705
Practice Address - Country:US
Practice Address - Phone:831-462-7700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-08
Last Update Date:2024-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
CA63854363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant