Provider Demographics
NPI:1730186024
Name:CAMPBELL, CANDACE (PA-C)
Entity type:Individual
Prefix:
First Name:CANDACE
Middle Name:
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:182 16TH ST
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:CO
Mailing Address - Zip Code:80807-1649
Mailing Address - Country:US
Mailing Address - Phone:719-346-4898
Mailing Address - Fax:719-346-9485
Practice Address - Street 1:182 16TH ST
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:CO
Practice Address - Zip Code:80807-1649
Practice Address - Country:US
Practice Address - Phone:719-346-9481
Practice Address - Fax:719-346-9485
Is Sole Proprietor?:No
Enumeration Date:2005-07-01
Last Update Date:2012-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1630363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO28659376Medicaid
R32044Medicare UPIN
CO800182Medicare ID - Type Unspecified