Provider Demographics
NPI:1972627990
Name:MOORE, PAMELA JUNE (RAD INTERN)
Entity type:Individual
Prefix:MRS
First Name:PAMELA
Middle Name:JUNE
Last Name:MOORE
Suffix:
Gender:F
Credentials:RAD INTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:555 MATMOR RD
Mailing Address - Street 2:#169
Mailing Address - City:WOODLAND
Mailing Address - State:CA
Mailing Address - Zip Code:95776-5726
Mailing Address - Country:US
Mailing Address - Phone:530-383-7019
Mailing Address - Fax:
Practice Address - Street 1:15450 COUNTY ROAD 99
Practice Address - Street 2:
Practice Address - City:WOODLAND
Practice Address - State:CA
Practice Address - Zip Code:95695-9339
Practice Address - Country:US
Practice Address - Phone:530-668-9627
Practice Address - Fax:530-668-8528
Is Sole Proprietor?:No
Enumeration Date:2007-03-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARS4253174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARS4253OtherRADI