Healthcare Provider Details

I. General information

NPI: 1730186024
Provider Name (Legal Business Name): CANDACE CAMPBELL PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2005
Last Update Date: 08/08/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

182 16TH ST
BURLINGTON CO
80807-1649
US

IV. Provider business mailing address

182 16TH ST
BURLINGTON CO
80807-1649
US

V. Phone/Fax

Practice location:
  • Phone: 719-346-9481
  • Fax: 719-346-9485
Mailing address:
  • Phone: 719-346-4898
  • Fax: 719-346-9485

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number1630
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: