Provider Demographics
NPI:1861057614
Name:RASTETTER, PAMELA
Entity type:Individual
Prefix:
First Name:PAMELA
Middle Name:
Last Name:RASTETTER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:PAMELA
Other - Middle Name:
Other - Last Name:BAZAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:425 W 5TH ST
Mailing Address - Street 2:
Mailing Address - City:EAST LIVERPOOL
Mailing Address - State:OH
Mailing Address - Zip Code:43920-2498
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:123 W 6TH ST
Practice Address - Street 2:
Practice Address - City:EAST LIVERPOOL
Practice Address - State:OH
Practice Address - Zip Code:43920-2921
Practice Address - Country:US
Practice Address - Phone:330-385-7170
Practice Address - Fax:330-385-6359
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-07
Last Update Date:2022-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34.015773207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine