Provider Demographics
NPI:1508877382
Name:ALLEN, ROBERTA R (PA)
Entity Type:Individual
Prefix:
First Name:ROBERTA
Middle Name:R
Last Name:ALLEN
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:PO BOX 255228
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95865-5228
Mailing Address - Country:US
Mailing Address - Phone:800-470-0071
Mailing Address - Fax:
Practice Address - Street 1:2020 SUTTER PL
Practice Address - Street 2:SUITE 101
Practice Address - City:DAVIS
Practice Address - State:CA
Practice Address - Zip Code:95616-6201
Practice Address - Country:US
Practice Address - Phone:530-750-5900
Practice Address - Fax:530-750-5804
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA18229363A00000X
CANP15895363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Not Answered363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAQ60195Medicare UPIN
CA0PA182290Medicare ID - Type Unspecified