Basic Information
| Provider Information | |||||||||
| NPI: | 1215129689 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MYSORE | ||||||||
| FirstName: | PRARTHANA | ||||||||
| MiddleName: | NAREN | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | SHRINERS HOSPITALS FOR CHILDREN NORTHERN CALIFORNIA | ||||||||
| Address2: | 2425 STOCKTON BLVD | ||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95817 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9164532000 | ||||||||
| FaxNumber: | 9164532373 | ||||||||
| Practice Location | |||||||||
| Address1: | 2425 STOCKTON BLVD | ||||||||
| Address2: | |||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958172215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9164532000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2007 | ||||||||
| LastUpdateDate: | 09/04/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 3663 | AZ | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 52524 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 52524 | 01 | CA | PA BOARD OF CALIFORNIA | OTHER | 3663 | 01 | AZ | ARIZONA STATE LICENSE | OTHER |