Basic Information
| Provider Information | |||||||||
| NPI: | 1487854055 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DENSON | ||||||||
| FirstName: | PAMELA | ||||||||
| MiddleName: | KOTHARI | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2001 S WOODRUFF AVE | ||||||||
| Address2: | SUITE 10 | ||||||||
| City: | IDAHO FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 834046374 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082060527 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2001 S WOODRUFF AVE | ||||||||
| Address2: | SUITE 10 | ||||||||
| City: | IDAHO FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 834046374 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4178850828 | ||||||||
| FaxNumber: | 4178867383 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/23/2007 | ||||||||
| LastUpdateDate: | 02/16/2016 | ||||||||
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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 | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207V00000X | N5163 | TX | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207V00000X | 2012007463 | MO | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207V00000X | M-12616 | ID | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 1487854055 | 05 | MO | MEDICAID | 431560263 | 01 | MO | TRICARE | OTHER | 194646001 | 05 | AR | MEDICAID | P01128235 | 01 | MO | RR MCR | OTHER |