Provider Demographics
NPI:1528224573
Name:PATAM, MARIENIDA BOEHN (PA-C)
Entity Type:Individual
Prefix:
First Name:MARIENIDA
Middle Name:BOEHN
Last Name:PATAM
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:11 TECHNOLOGY DR
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92618-2302
Mailing Address - Country:US
Mailing Address - Phone:949-923-3277
Mailing Address - Fax:855-812-5865
Practice Address - Street 1:724 S EL CAMINO REAL
Practice Address - Street 2:
Practice Address - City:SAN CLEMENTE
Practice Address - State:CA
Practice Address - Zip Code:92672-4250
Practice Address - Country:US
Practice Address - Phone:949-493-6113
Practice Address - Fax:949-493-5851
Is Sole Proprietor?:No
Enumeration Date:2008-07-30
Last Update Date:2017-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA19828363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACB209291Medicare PIN