Provider Demographics
NPI:1245682194
Name:PAYNE, AUDREY ELIZABETH
Entity type:Individual
Prefix:MISS
First Name:AUDREY
Middle Name:ELIZABETH
Last Name:PAYNE
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 1:615 OCEAN ST
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95060-4005
Mailing Address - Country:US
Mailing Address - Phone:831-425-7991
Mailing Address - Fax:831-425-7346
Practice Address - Street 1:615 OCEAN ST
Practice Address - Street 2:
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95060-4005
Practice Address - Country:US
Practice Address - Phone:831-425-7991
Practice Address - Fax:831-425-7346
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-04
Last Update Date:2018-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA53891363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant