Provider Demographics
NPI:1730392440
Name:NYGREN, PAMELA (NCLC ABOC)
Entity type:Individual
Prefix:
First Name:PAMELA
Middle Name:
Last Name:NYGREN
Suffix:
Gender:F
Credentials:NCLC ABOC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:926 E PRINCE RD
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85719-1755
Mailing Address - Country:US
Mailing Address - Phone:520-293-2111
Mailing Address - Fax:520-293-2112
Practice Address - Street 1:926 E PRINCE RD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85719-1755
Practice Address - Country:US
Practice Address - Phone:520-293-2111
Practice Address - Fax:520-293-2112
Is Sole Proprietor?:No
Enumeration Date:2007-05-08
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2164I156FC0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FC0801XEye and Vision Services ProvidersTechnician/TechnologistContact Lens Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAZ2000390Medicare UPIN