Basic Information
| Provider Information | |||||||||
| NPI: | 1013348507 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | AJIDUAH | ||||||||
| FirstName: | VALERIE | ||||||||
| MiddleName: | O. | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 625 FAIR OAKS AVE STE 270 | ||||||||
| Address2: | |||||||||
| City: | SOUTH PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 910305801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6263462455 | ||||||||
| FaxNumber: | 6266393005 | ||||||||
| Practice Location | |||||||||
| Address1: | 3946 NORWOOD AVE | ||||||||
| Address2: | |||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958381092 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9165640521 | ||||||||
| FaxNumber: | 8778602907 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/09/2013 | ||||||||
| LastUpdateDate: | 03/30/2018 | ||||||||
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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 | 51325 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | SAC POD- EFF 5/22/14 | 05 | CA | MEDICAID | P0146687 - DV5277 | 01 | CA | RR MEDICARE - 55TH ST, NORWOOD, MARYSVILLE, MACK RD & CITRUS HEIGHTS LOCATIONS | OTHER |