Provider Demographics
NPI:1205893195
Name:PATRICK, DEBRA J (PA-C)
Entity type:Individual
Prefix:
First Name:DEBRA
Middle Name:J
Last Name:PATRICK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34800 BOB WILSON DR STE 3
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92134-1003
Mailing Address - Country:US
Mailing Address - Phone:619-532-7200
Mailing Address - Fax:619-532-7234
Practice Address - Street 1:34800 BOB WILSON DR STE 3
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92134-5301
Practice Address - Country:US
Practice Address - Phone:619-532-7200
Practice Address - Fax:619-532-7234
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2021-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1818646363AM0700X
CA18646363AS0400X
TXPA00998363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8G4279Medicare ID - Type Unspecified
TXS68084Medicare UPIN