MEDICARE: CAMERON PHAN

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	2255A2300X	Athletic Trainer
2	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1912648874
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CAMERON PHAN

Provider Business Mailing Address
First Line	:	2635 PROSPECT RIDGE DR APT 9214
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76110-2574
Country	:	US
Telephone Number	:	703-965-7603
Fax Number	:

Provider Business Practice Location Address
First Line	:	2900 STADIUM DR
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76109-1380
Country	:	US
Telephone Number	:	817-257-3764
Fax Number	:

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

Provider Enumeration Date	:	04/05/2022
Last Update Date	:	04/05/2022

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Directions to “ CAMERON PHAN ” Practice Location

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