Basic Information
| Provider Information | |||||||||
| NPI: | 1730186024 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CAMPBELL | ||||||||
| FirstName: | CANDACE | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 182 16TH ST | ||||||||
| Address2: | |||||||||
| City: | BURLINGTON | ||||||||
| State: | CO | ||||||||
| PostalCode: | 808071649 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7193464898 | ||||||||
| FaxNumber: | 7193469485 | ||||||||
| Practice Location | |||||||||
| Address1: | 182 16TH ST | ||||||||
| Address2: | |||||||||
| City: | BURLINGTON | ||||||||
| State: | CO | ||||||||
| PostalCode: | 808071649 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7193469481 | ||||||||
| FaxNumber: | 7193469485 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/01/2005 | ||||||||
| LastUpdateDate: | 08/08/2012 | ||||||||
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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 | 1630 | CO | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 28659376 | 05 | CO | MEDICAID |