Provider Demographics
NPI:1942361027
Name:PAYNE, AMBER (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:
Last Name:PAYNE
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 812
Mailing Address - Street 2:
Mailing Address - City:DANA POINT
Mailing Address - State:CA
Mailing Address - Zip Code:92629-0812
Mailing Address - Country:US
Mailing Address - Phone:951-696-7587
Mailing Address - Fax:
Practice Address - Street 1:41880 KALMIA ST STE 100
Practice Address - Street 2:
Practice Address - City:MURRIETA
Practice Address - State:CA
Practice Address - Zip Code:92562-8835
Practice Address - Country:US
Practice Address - Phone:951-696-7587
Practice Address - Fax:951-461-6973
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2015-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA17610363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant