Provider Demographics
NPI:1881775252
Name:DAVID, ANITA ROSEANN (PAC)
Entity type:Individual
Prefix:
First Name:ANITA
Middle Name:ROSEANN
Last Name:DAVID
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:MS
Other - First Name:ANITA
Other - Middle Name:ROSEANN
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3061 VIA MADERAS ST
Mailing Address - Street 2:
Mailing Address - City:ALTADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91001-1546
Mailing Address - Country:US
Mailing Address - Phone:626-825-9646
Mailing Address - Fax:
Practice Address - Street 1:3061 VIA MADERAS ST
Practice Address - Street 2:
Practice Address - City:ALTADENA
Practice Address - State:CA
Practice Address - Zip Code:91001-1546
Practice Address - Country:US
Practice Address - Phone:626-825-9646
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2009-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA15726363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
S91696Medicare UPIN