Provider Demographics
NPI:1780808915
Name:SHRADER, PAMELA ANNE (PA-C)
Entity type:Individual
Prefix:MS
First Name:PAMELA
Middle Name:ANNE
Last Name:SHRADER
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 1:3855 DOVER RDG APT 9
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-7250
Mailing Address - Country:US
Mailing Address - Phone:541-660-2765
Mailing Address - Fax:
Practice Address - Street 1:1111 CRATER LAKE AVE
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-6241
Practice Address - Country:US
Practice Address - Phone:541-732-5059
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA00961363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORQ09498Medicare UPIN