Healthcare Provider Details

I. General information

NPI: 1639872864
Provider Name (Legal Business Name): CAMERON CUPP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/27/2023
Last Update Date: 06/22/2026
Certification Date: 06/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

850 REPUBLICAN ST
SEATTLE WA
98109-4725
US

IV. Provider business mailing address

3181 SW SAM JACKSON PARK RD
PORTLAND OR
97239-3011
US

V. Phone/Fax

Practice location:
  • Phone: 206-543-6806
  • Fax:
Mailing address:
  • Phone: 503-494-8211
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberMD.MD.70137824
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: