Provider Demographics
NPI:1043837479
Name:CAMACHO, SUSANA
Entity Type:Individual
Prefix:
First Name:SUSANA
Middle Name:
Last Name:CAMACHO
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 1:3349 G ST STE A
Mailing Address - Street 2:
Mailing Address - City:MERCED
Mailing Address - State:CA
Mailing Address - Zip Code:95340-0978
Mailing Address - Country:US
Mailing Address - Phone:209-600-4422
Mailing Address - Fax:
Practice Address - Street 1:3320 TULLY RD
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-0800
Practice Address - Country:US
Practice Address - Phone:209-550-5200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-01
Last Update Date:2022-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95014376363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily