Provider Demographics
NPI:1598849374
Name:OLDENBURG, RICKY A (PA-C)
Entity Type:Individual
Prefix:
First Name:RICKY
Middle Name:A
Last Name:OLDENBURG
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27168 NEWPORT RD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:MENIFEE
Mailing Address - State:CA
Mailing Address - Zip Code:92584-7383
Mailing Address - Country:US
Mailing Address - Phone:951-246-3033
Mailing Address - Fax:951-246-7373
Practice Address - Street 1:36243 INLAND VALLEY DRIVE
Practice Address - Street 2:SUITE 180
Practice Address - City:WILDOMAR
Practice Address - State:CA
Practice Address - Zip Code:92595
Practice Address - Country:US
Practice Address - Phone:951-600-0110
Practice Address - Fax:951-600-4645
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2012-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA16971363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q04470Medicare UPIN
0PA169711Medicare ID - Type Unspecified