Provider Demographics
NPI:1215129689
Name:MYSORE, PRARTHANA NAREN (PA-C)
Entity type:Individual
Prefix:MRS
First Name:PRARTHANA
Middle Name:NAREN
Last Name:MYSORE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:SHRINERS HOSPITALS FOR CHILDREN NORTHERN CALIFORNIA
Mailing Address - Street 2:2425 STOCKTON BLVD
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95817
Mailing Address - Country:US
Mailing Address - Phone:916-453-2000
Mailing Address - Fax:916-453-2373
Practice Address - Street 1:2425 STOCKTON BLVD
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95817-2215
Practice Address - Country:US
Practice Address - Phone:916-453-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-09
Last Update Date:2019-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3663363A00000X
CA52524363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA52524OtherPA BOARD OF CALIFORNIA
AZ3663OtherARIZONA STATE LICENSE