Basic Information
| Provider Information | |||||||||
| NPI: | 1528058898 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PENDLETON | ||||||||
| FirstName: | PHILLIP | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 40 RYAN CT | ||||||||
| Address2: | STE 100 | ||||||||
| City: | MONTEREY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 939407866 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8317189701 | ||||||||
| FaxNumber: | 8318861538 | ||||||||
| Practice Location | |||||||||
| Address1: | 275 THE CROSSROADS BLVD STE A | ||||||||
| Address2: | |||||||||
| City: | CARMEL | ||||||||
| State: | CA | ||||||||
| PostalCode: | 93923 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8317189701 | ||||||||
| FaxNumber: | 8318861538 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/26/2005 | ||||||||
| LastUpdateDate: | 10/05/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 71000962A | IN | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363L00000X | 14610 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LF0000X | 4984P | KY | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 78017547 | 05 | KY | MEDICAID | 200379310 | 05 | IN | MEDICAID | CA200946 | 01 | CA | MEDICARE PIN | OTHER |