MEDICARE: MR. GORDON H CAMPBELL PA

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	363A00000X	Physician Assistant

General Provider Information

NPI Number	:	1710947767
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. GORDON H CAMPBELL PA

Provider Business Mailing Address
First Line	:	3278 MITCHELL BLVD
Second Line	:
City	:	MOODY AFB
State	:	GA
Zip	:	31699-1500
Country	:	US
Telephone Number	:	850-499-0257
Fax Number	:

Provider Business Practice Location Address
First Line	:	3278 MITCHELL BLVD
Second Line	:
City	:	MOODY AFB
State	:	GA
Zip	:	31699-1500
Country	:	US
Telephone Number	:	850-499-0257
Fax Number	:

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

Provider Enumeration Date	:	03/24/2006
Last Update Date	:	04/30/2014

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