Provider Demographics
NPI:1982028387
Name:BLACK, PAMELA
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:
Last Name:BLACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5405 N PERSHING AVE
Mailing Address - Street 2:C1
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95207-5451
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5405 N PERSHING AVE
Practice Address - Street 2:C1
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207-5451
Practice Address - Country:US
Practice Address - Phone:209-476-1959
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-06
Last Update Date:2014-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program