Provider Demographics
NPI:1326028374
Name:DORNER, PAMELA (PT)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:
Last Name:DORNER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2645 AUGUSTA
Mailing Address - Street 2:
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92782-1201
Mailing Address - Country:US
Mailing Address - Phone:714-730-5010
Mailing Address - Fax:
Practice Address - Street 1:4200 TRABUCO RD
Practice Address - Street 2:SUITE 150
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92620-3600
Practice Address - Country:US
Practice Address - Phone:949-651-9199
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-17
Last Update Date:2010-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 10694225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW14644Medicare ID - Type UnspecifiedPROVIDER ID NUMBER