Provider Demographics
NPI:1528058898
Name:PENDLETON, PHILLIP E (APRN)
Entity type:Individual
Prefix:
First Name:PHILLIP
Middle Name:E
Last Name:PENDLETON
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 RYAN CT
Mailing Address - Street 2:STE 100
Mailing Address - City:MONTEREY
Mailing Address - State:CA
Mailing Address - Zip Code:93940-7866
Mailing Address - Country:US
Mailing Address - Phone:831-718-9701
Mailing Address - Fax:831-886-1538
Practice Address - Street 1:275 THE CROSSROADS BLVD STE A
Practice Address - Street 2:
Practice Address - City:CARMEL
Practice Address - State:CA
Practice Address - Zip Code:93923
Practice Address - Country:US
Practice Address - Phone:831-718-9701
Practice Address - Fax:831-886-1538
Is Sole Proprietor?:No
Enumeration Date:2005-10-26
Last Update Date:2018-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71000962A363L00000X
CA14610363L00000X
KY4984P363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY78017547Medicaid
IN200379310Medicaid
CACA200946OtherMEDICARE PIN
IN200379310Medicaid
IN146470UUUMedicare ID - Type Unspecified