Provider Demographics
NPI:1871044404
Name:PATTERSON, PAULA JO (PT DPT OCS)
Entity Type:Individual
Prefix:
First Name:PAULA
Middle Name:JO
Last Name:PATTERSON
Suffix:
Gender:F
Credentials:PT DPT OCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:275 W HOSPITALITY LN STE 103
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92408-3238
Mailing Address - Country:US
Mailing Address - Phone:909-567-2221
Mailing Address - Fax:909-763-3216
Practice Address - Street 1:275 W HOSPITALITY LN STE 103
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92408-3238
Practice Address - Country:US
Practice Address - Phone:909-567-2221
Practice Address - Fax:909-763-3216
Is Sole Proprietor?:No
Enumeration Date:2016-10-19
Last Update Date:2020-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA38232225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACA234919Medicare PIN
CACA234921Medicare PIN
CACA228954Medicare PIN
CACA228955Medicare PIN
CACA28953Medicare PIN
CACA234917Medicare PIN
CACA228956Medicare PIN
CACA234916Medicare PIN
CACA234918Medicare PIN
CACA234920Medicare PIN