Healthcare Provider Details

I. General information

NPI: 1912474495
Provider Name (Legal Business Name): CAMERON CALEB CHIN PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2018
Last Update Date: 09/02/2022
Certification Date: 09/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

909 9TH AVE STE 400
FORT WORTH TX
76104-3932
US

IV. Provider business mailing address

1000 W CANNON ST
FORT WORTH TX
76104-3029
US

V. Phone/Fax

Practice location:
  • Phone: 817-877-4105
  • Fax: 817-348-9797
Mailing address:
  • Phone: 817-725-7900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA12394
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: