Basic Information
| Provider Information | |||||||||
| NPI: | 1215913512 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DECAMP | ||||||||
| FirstName: | RAQUEL | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1838 AMERICAN WAY | ||||||||
| Address2: | |||||||||
| City: | LAWRENCEVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300436611 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709957622 | ||||||||
| FaxNumber: | 7709957854 | ||||||||
| Practice Location | |||||||||
| Address1: | 1700 HOSPITAL SOUTH DR | ||||||||
| Address2: | SUITE 302 | ||||||||
| City: | AUSTELL | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301066810 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7707390999 | ||||||||
| FaxNumber: | 6783244275 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/19/2005 | ||||||||
| LastUpdateDate: | 11/05/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 004821 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 666236332G | 05 | GA | MEDICAID | 666236332F | 05 | GA | MEDICAID | 666236332C | 05 | GA | MEDICAID | 666236332D | 05 | GA | MEDICAID | 666236332E | 05 | GA | MEDICAID | 20526 | 05 | NE | MEDICAID |