Provider Demographics
NPI:1790131316
Name:EGGEBROTEN, CAMILLE AMEDE
Entity type:Individual
Prefix:
First Name:CAMILLE
Middle Name:AMEDE
Last Name:EGGEBROTEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 BOONE RD
Mailing Address - Street 2:
Mailing Address - City:BREMERTON
Mailing Address - State:WA
Mailing Address - Zip Code:98312-1894
Mailing Address - Country:US
Mailing Address - Phone:360-475-4000
Mailing Address - Fax:
Practice Address - Street 1:2050 BARB ST STE A
Practice Address - Street 2:
Practice Address - City:SILVERDALE
Practice Address - State:WA
Practice Address - Zip Code:98315-2050
Practice Address - Country:US
Practice Address - Phone:360-315-4346
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-12
Last Update Date:2024-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X, 171000000X
VA01012628612083X0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No171000000XOther Service ProvidersMilitary Health Care Provider
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAD0000Medicare UPIN