Provider Demographics
NPI:1710132642
Name:HEADRICK, SHARON (PA)
Entity Type:Individual
Prefix:MISS
First Name:SHARON
Middle Name:
Last Name:HEADRICK
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 1:5944 COURTLAND DR
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92506
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4646 BROCKTON AVE
Practice Address - Street 2:SUITE 202
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92506-0128
Practice Address - Country:US
Practice Address - Phone:951-774-2942
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-19
Last Update Date:2008-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA15358363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical