Provider Demographics
NPI:1710322664
Name:WHARTON, ALLYSE (PA-C)
Entity Type:Individual
Prefix:
First Name:ALLYSE
Middle Name:
Last Name:WHARTON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ALLYSE
Other - Middle Name:
Other - Last Name:FIDLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:2 EMBARCADERO CTR LBBY LEVEL
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94111-3823
Mailing Address - Country:US
Mailing Address - Phone:415-578-3100
Mailing Address - Fax:415-291-0489
Practice Address - Street 1:350 30TH ST
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94609-3424
Practice Address - Country:US
Practice Address - Phone:510-465-6700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-06
Last Update Date:2016-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA22900363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical