Provider Demographics
NPI:1164561353
Name:KNICKERBOCKER, PAMELA ROSE (DO)
Entity Type:Individual
Prefix:DR
First Name:PAMELA
Middle Name:ROSE
Last Name:KNICKERBOCKER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:PAMELA
Other - Middle Name:ROSE
Other - Last Name:GARNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:1035 PLACER ST
Mailing Address - Street 2:
Mailing Address - City:REDDING
Mailing Address - State:CA
Mailing Address - Zip Code:96001-1125
Mailing Address - Country:US
Mailing Address - Phone:530-246-5710
Mailing Address - Fax:
Practice Address - Street 1:1006 W PLEASANT ST
Practice Address - Street 2:
Practice Address - City:AVON PARK
Practice Address - State:FL
Practice Address - Zip Code:33825-2966
Practice Address - Country:US
Practice Address - Phone:863-453-3121
Practice Address - Fax:863-452-2823
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2023-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA2012777207Q00000X
FLOS19486207Q00000X
OK4409207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200182150AMedicaid
OK730765084Medicare UPIN