Provider Demographics
NPI:1174514822
Name:DIAS, PAMELA JEAN (NURSE PRACTITIONER)
Entity type:Individual
Prefix:MS
First Name:PAMELA
Middle Name:JEAN
Last Name:DIAS
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:PAMELA
Other - Middle Name:JEAN
Other - Last Name:BURNSIDE-DIAS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:NURSE PRACTITIONER
Mailing Address - Street 1:7373 WEST LN
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95210-3377
Mailing Address - Country:US
Mailing Address - Phone:209-476-5405
Mailing Address - Fax:209-476-3708
Practice Address - Street 1:7373 WEST LN
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95210-3377
Practice Address - Country:US
Practice Address - Phone:209-476-5405
Practice Address - Fax:209-476-3708
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-02
Last Update Date:2013-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA219713363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ23665ZMedicare PIN
CAP71740Medicare UPIN