Provider Demographics
NPI:1356689442
Name:PATAM, MARIANITO (CPT1)
Entity Type:Individual
Prefix:
First Name:MARIANITO
Middle Name:
Last Name:PATAM
Suffix:
Gender:M
Credentials:CPT1
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3101 LEGENDARIO
Mailing Address - Street 2:
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92673-3815
Mailing Address - Country:US
Mailing Address - Phone:949-338-4976
Mailing Address - Fax:949-542-4145
Practice Address - Street 1:3101 LEGENDARIO
Practice Address - Street 2:
Practice Address - City:SAN CLEMENTE
Practice Address - State:CA
Practice Address - Zip Code:92673-3815
Practice Address - Country:US
Practice Address - Phone:949-338-4976
Practice Address - Fax:949-542-4145
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-23
Last Update Date:2013-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACPT00005346246RP1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomy