MEDICARE: MRS. KYLIE ELIZABETH CAMPBELL PA-C

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	363AM0700X	Medical Physician Assistant	19985	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	952979638	OTHER	CA	FEDERAL ID NUMBER

General Provider Information

NPI Number	:	1558514281
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KYLIE ELIZABETH CAMPBELL PA-C

Provider Business Mailing Address
First Line	:	PO BOX 5156
Second Line	:
City	:	EL DORADO HILLS
State	:	CA
Zip	:	95762-0003
Country	:	US
Telephone Number	:	530-400-9674
Fax Number	:	916-939-1800

Provider Business Practice Location Address
First Line	:	4921 GOLDEN FOOTHILL PKWY
Second Line	:
City	:	EL DORADO HILLS
State	:	CA
Zip	:	95762-9632
Country	:	US
Telephone Number	:	916-983-5771
Fax Number	:	916-939-1800

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

Provider Enumeration Date	:	10/26/2008
Last Update Date	:	05/21/2020

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