Provider Demographics
NPI:1669534970
Name:EBBECKE, PATRICIA JANE (NP)
Entity type:Individual
Prefix:MS
First Name:PATRICIA
Middle Name:JANE
Last Name:EBBECKE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14185 HOPI RD
Mailing Address - Street 2:
Mailing Address - City:APPLE VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92307-5716
Mailing Address - Country:US
Mailing Address - Phone:760-247-4505
Mailing Address - Fax:
Practice Address - Street 1:12675 HESPERIA RD
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92395-5878
Practice Address - Country:US
Practice Address - Phone:760-241-8063
Practice Address - Fax:760-241-5037
Is Sole Proprietor?:No
Enumeration Date:2006-12-14
Last Update Date:2009-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA280926363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABH314ZMedicare PIN