Basic Information
| Provider Information | |||||||||
| NPI: | 1063834331 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PLUMMER | ||||||||
| FirstName: | KARISSA | ||||||||
| MiddleName: | BARTHOLME | ||||||||
| NamePrefix: | |||||||||
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| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BARTHOLME | ||||||||
| OtherFirstName: | KARISSA | ||||||||
| OtherMiddleName: | MARIE | ||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 10790 RANCHO BERNARDO RD | ||||||||
| Address2: | MAIL DROP 4S-205 | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921275705 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6192783300 | ||||||||
| FaxNumber: | 6192783310 | ||||||||
| Practice Location | |||||||||
| Address1: | 501 WASHINGTON ST STE 600 | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921032239 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6192783340 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/06/2014 | ||||||||
| LastUpdateDate: | 05/26/2021 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 51246 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | PA51246 | CA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.