Provider Demographics
NPI:1639145386
Name:PRYOR, DONNA LYNN (PA-C)
Entity type:Individual
Prefix:
First Name:DONNA
Middle Name:LYNN
Last Name:PRYOR
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 1:542 SAGEWALK COURT
Mailing Address - Street 2:
Mailing Address - City:OAKDALE
Mailing Address - State:CA
Mailing Address - Zip Code:95361
Mailing Address - Country:US
Mailing Address - Phone:209-988-0943
Mailing Address - Fax:
Practice Address - Street 1:1324 NELSON AVE. SUITE B
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350
Practice Address - Country:US
Practice Address - Phone:209-524-9481
Practice Address - Fax:209-524-9486
Is Sole Proprietor?:No
Enumeration Date:2006-02-23
Last Update Date:2023-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AS0400X
CAPA 14350363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP18159Medicare UPIN