Provider Demographics
NPI:1508147950
Name:RATHBURN, PAMELA JANE (NP)
Entity Type:Individual
Prefix:PROF
First Name:PAMELA
Middle Name:JANE
Last Name:RATHBURN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:405 LOCUST AVE
Mailing Address - Street 2:
Mailing Address - City:OAKDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11769-1651
Mailing Address - Country:US
Mailing Address - Phone:631-868-1244
Mailing Address - Fax:631-567-1648
Practice Address - Street 1:48 SAMUELS PATH
Practice Address - Street 2:
Practice Address - City:MILLER PLACE
Practice Address - State:NY
Practice Address - Zip Code:11764-1921
Practice Address - Country:US
Practice Address - Phone:631-721-8872
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-30
Last Update Date:2022-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF360369-1363LX0001X
NYF401659-1363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology