Provider Demographics
NPI:1992750376
Name:HILDABRAND, STAR (PA-C)
Entity type:Individual
Prefix:
First Name:STAR
Middle Name:
Last Name:HILDABRAND
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:PO BOX 86
Mailing Address - Street 2:
Mailing Address - City:AVERY
Mailing Address - State:CA
Mailing Address - Zip Code:95224-0086
Mailing Address - Country:US
Mailing Address - Phone:209-728-1694
Mailing Address - Fax:209-729-4530
Practice Address - Street 1:222 S MAIN ST
Practice Address - Street 2:
Practice Address - City:ANGELS CAMP
Practice Address - State:CA
Practice Address - Zip Code:95222
Practice Address - Country:US
Practice Address - Phone:209-736-0813
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA 12518363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA 12518OtherMEDICAL LICENSE NUMBER
CAPA 12518OtherMEDICAL LICENSE NUMBER