Provider Demographics
NPI:1609987619
Name:DOUGHERTY, CLARA WERNER (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:CLARA
Middle Name:WERNER
Last Name:DOUGHERTY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:CLARA
Other - Middle Name:
Other - Last Name:WERNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:10790 RANCHO BERNARDO RD
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92127-5705
Mailing Address - Country:US
Mailing Address - Phone:760-704-5730
Mailing Address - Fax:
Practice Address - Street 1:9850 GENESEE AVE
Practice Address - Street 2:SUITE 400
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-1224
Practice Address - Country:US
Practice Address - Phone:858-453-5944
Practice Address - Fax:858-429-7925
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2023-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA17439363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAEE582XOtherMEDICARE PTAN
CAP75713Medicare UPIN
CAEE582XOtherMEDICARE PTAN