Provider Demographics
NPI:1902275993
Name:DETTMAR, MEREDITH (PA-C)
Entity Type:Individual
Prefix:
First Name:MEREDITH
Middle Name:
Last Name:DETTMAR
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MEREDITH
Other - Middle Name:
Other - Last Name:EINSPAHR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:16705 CAROB AVE
Mailing Address - Street 2:
Mailing Address - City:CHINO HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91709-6524
Mailing Address - Country:US
Mailing Address - Phone:909-816-4256
Mailing Address - Fax:
Practice Address - Street 1:10787 LAUREL ST
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-3828
Practice Address - Country:US
Practice Address - Phone:099-982-7741
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-19
Last Update Date:2024-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA52882363A00000X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant