Provider Demographics
NPI:1821577222
Name:PLANTAK, NATASHA STEPHANIE (PA)
Entity Type:Individual
Prefix:
First Name:NATASHA
Middle Name:STEPHANIE
Last Name:PLANTAK
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 1:36558 ALBATROSS ST
Mailing Address - Street 2:
Mailing Address - City:BEAUMONT
Mailing Address - State:CA
Mailing Address - Zip Code:92223-8127
Mailing Address - Country:US
Mailing Address - Phone:301-830-1161
Mailing Address - Fax:
Practice Address - Street 1:264 N HIGHLAND SPRINGS AVE STE 4
Practice Address - Street 2:
Practice Address - City:BANNING
Practice Address - State:CA
Practice Address - Zip Code:92220-3082
Practice Address - Country:US
Practice Address - Phone:951-769-0079
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-07
Last Update Date:2020-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA57944363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant