Provider Demographics
NPI:1972719383
Name:NATHAN, PAMELA SANDRA (LAC)
Entity Type:Individual
Prefix:MS
First Name:PAMELA
Middle Name:SANDRA
Last Name:NATHAN
Suffix:
Gender:F
Credentials:LAC
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 927747
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92192-7747
Mailing Address - Country:US
Mailing Address - Phone:858-452-2280
Mailing Address - Fax:858-452-1113
Practice Address - Street 1:4455 VISION DR
Practice Address - Street 2:7
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92121-1921
Practice Address - Country:US
Practice Address - Phone:619-884-2280
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2779171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAC0027790OtherMEDICAL