Provider Demographics
NPI:1902243298
Name:DIXON, CAMILLE NICOLE (MPAS)
Entity Type:Individual
Prefix:
First Name:CAMILLE
Middle Name:NICOLE
Last Name:DIXON
Suffix:
Gender:F
Credentials:MPAS
Other - Prefix:
Other - First Name:CAMILLE
Other - Middle Name:NICOLE
Other - Last Name:COOK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6195 LUSK BLVD STE 250
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92121-3715
Mailing Address - Country:US
Mailing Address - Phone:858-859-1188
Mailing Address - Fax:
Practice Address - Street 1:6195 LUSK BLVD STE 250
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92121-3715
Practice Address - Country:US
Practice Address - Phone:858-859-1188
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-28
Last Update Date:2022-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8512355-1206363A00000X
PAMA056088363A00000X
CA22984363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant