MEDICARE: MR. TIMOTHY J. CAMASTA PAC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	PA12294	CA
2	363AM0700X	Medical Physician Assistant	2353	CO
3	2084P0301X	Brain Injury Medicine (Psychiatry & Neurology) Physician	PA2353	CO

General Provider Information

NPI Number	:	1104885615
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. TIMOTHY J. CAMASTA PAC

Provider Business Mailing Address
First Line	:	7092 HARR AVE BLDG 6492
Second Line	:
City	:	FORT CARSON
State	:	CO
Zip	:	80902-2190
Country	:	US
Telephone Number	:	719-524-5217
Fax Number	:

Provider Business Practice Location Address
First Line	:	7092 HARR AVE BLDG 6492
Second Line	:
City	:	FORT CARSON
State	:	CO
Zip	:	80902-2190
Country	:	US
Telephone Number	:	719-524-5217
Fax Number	:	719-526-3088

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/22/2006
Last Update Date	:	11/13/2023

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