Provider Demographics
NPI:1538195730
Name:PRYDE, JULIE (PA)
Entity type:Individual
Prefix:
First Name:JULIE
Middle Name:
Last Name:PRYDE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 31396
Mailing Address - Street 2:
Mailing Address - City:WALNUT CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:94598-8396
Mailing Address - Country:US
Mailing Address - Phone:925-939-8585
Mailing Address - Fax:925-933-2709
Practice Address - Street 1:2405 SHADELANDS DR
Practice Address - Street 2:
Practice Address - City:WALNUT CREEK
Practice Address - State:CA
Practice Address - Zip Code:94598-2444
Practice Address - Country:US
Practice Address - Phone:925-939-8585
Practice Address - Fax:925-933-2709
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2013-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA16038363AS0400X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP50377Medicare UPIN
CA0PA160380Medicare PIN