Provider Demographics
NPI:1043309107
Name:DAFFERN, PAMELA J (MD)
Entity type:Individual
Prefix:
First Name:PAMELA
Middle Name:J
Last Name:DAFFERN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1020 TIJERAS AVE NE
Mailing Address - Street 2:SUITE 22
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87106-4749
Mailing Address - Country:US
Mailing Address - Phone:505-848-3124
Mailing Address - Fax:505-843-9037
Practice Address - Street 1:1020 TIJERAS AVE NE
Practice Address - Street 2:SUITE 22
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87106-4749
Practice Address - Country:US
Practice Address - Phone:505-848-3124
Practice Address - Fax:505-843-9037
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2016-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101059354207R00000X, 207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM1598933145OtherGROUP NPI
VA1396970281OtherGROUP NPI
NM94507520Medicaid
E10745Medicare UPIN