Provider Demographics
NPI:1275729584
Name:RODDEN, AMMIE WILSON (PA)
Entity Type:Individual
Prefix:
First Name:AMMIE
Middle Name:WILSON
Last Name:RODDEN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:737 MAYFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:STANFORD
Mailing Address - State:CA
Mailing Address - Zip Code:94305-1000
Mailing Address - Country:US
Mailing Address - Phone:650-320-8955
Mailing Address - Fax:
Practice Address - Street 1:866 CAMPUS DR
Practice Address - Street 2:
Practice Address - City:STANFORD
Practice Address - State:CA
Practice Address - Zip Code:94305-8508
Practice Address - Country:US
Practice Address - Phone:650-498-2336
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-20
Last Update Date:2007-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA19252363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AP2055Medicare Oscar/Certification
S75042Medicare UPIN