Basic Information
| Provider Information | |||||||||
| NPI: | 1821666389 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PAVLAK | ||||||||
| FirstName: | AMANDA | ||||||||
| MiddleName: | MARIE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12400 HIGH BLUFF DR | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921303077 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8668718519 | ||||||||
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| Practice Location | |||||||||
| Address1: | 12400 HIGH BLUFF DR | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921303077 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8668718519 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/11/2021 | ||||||||
| LastUpdateDate: | 10/08/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | 2181 | CT | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant | 225200000X | 06006385A | IN | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant | 225200000X | PTA012171 | OH | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.