Provider Demographics
NPI:1558396028
Name:VERDER BAUTISTA, PAMELA N (MD)
Entity Type:Individual
Prefix:DR
First Name:PAMELA
Middle Name:N
Last Name:VERDER BAUTISTA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:PAMELA
Other - Middle Name:
Other - Last Name:VERDER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:632 W GIBSON RD
Mailing Address - Street 2:
Mailing Address - City:WOODLAND
Mailing Address - State:CA
Mailing Address - Zip Code:95695
Mailing Address - Country:US
Mailing Address - Phone:530-666-1631
Mailing Address - Fax:
Practice Address - Street 1:632 W GIBSON RD
Practice Address - Street 2:
Practice Address - City:WOODLAND
Practice Address - State:CA
Practice Address - Zip Code:95695
Practice Address - Country:US
Practice Address - Phone:530-666-1631
Practice Address - Fax:530-668-4839
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2009-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA76841208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A768410Medicaid
CA00A768410OtherBLUE SHIELD
CA00A768410OtherBLUE SHIELD
CA00A768410Medicaid
CA00A768410Medicare PIN