Provider Demographics
NPI:1134790991
Name:THIRRUKOTLA, PAMELA RAMONA
Entity type:Individual
Prefix:
First Name:PAMELA RAMONA
Middle Name:
Last Name:THIRRUKOTLA
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 1:7550 ST PATRICK WAY APT 352
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:CA
Mailing Address - Zip Code:94568-4880
Mailing Address - Country:US
Mailing Address - Phone:703-457-0003
Mailing Address - Fax:
Practice Address - Street 1:350 JOHN MUIR PKWY STE 250
Practice Address - Street 2:
Practice Address - City:BRENTWOOD
Practice Address - State:CA
Practice Address - Zip Code:94513-5194
Practice Address - Country:US
Practice Address - Phone:925-308-8160
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-02
Last Update Date:2022-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA300292225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist