Healthcare Provider Details

I. General information

NPI: 1598729071
Provider Name (Legal Business Name): LETICIA CAMACHO PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: LETICIA CAMACHO-MOJICA PA-C

II. Dates (important events)

Enumeration Date: 04/13/2006
Last Update Date: 08/26/2026
Certification Date: 08/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

185 CEDAR LN STE L1
TEANECK NJ
07666-4303
US

IV. Provider business mailing address

20 W GOUVERNEUR AVE
RUTHERFORD NJ
07070-2626
US

V. Phone/Fax

Practice location:
  • Phone: 201-338-5186
  • Fax:
Mailing address:
  • Phone: 386-747-6007
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number25MP00739700
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA3045
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number004975-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: