Provider Demographics
NPI:1720134372
Name:SAVEDRA, TOMMY (PA)
Entity Type:Individual
Prefix:
First Name:TOMMY
Middle Name:
Last Name:SAVEDRA
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:TOM
Other - Middle Name:
Other - Last Name:SAVEDRA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA
Mailing Address - Street 1:PO BOX 660
Mailing Address - Street 2:
Mailing Address - City:MAMMOTH LAKES
Mailing Address - State:CA
Mailing Address - Zip Code:93546-0660
Mailing Address - Country:US
Mailing Address - Phone:760-932-7011
Mailing Address - Fax:760-932-7182
Practice Address - Street 1:221 TWIN LAKES RD
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CA
Practice Address - Zip Code:93517
Practice Address - Country:US
Practice Address - Phone:760-932-7011
Practice Address - Fax:760-932-7182
Is Sole Proprietor?:No
Enumeration Date:2007-01-26
Last Update Date:2018-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA13254363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical