Provider Demographics
NPI:1093224172
Name:CAMPOS, TASHANYA (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:
First Name:TASHANYA
Middle Name:
Last Name:CAMPOS
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 W CRYSTAL LAKE ST STE 200
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32806-4476
Mailing Address - Country:US
Mailing Address - Phone:407-254-2500
Mailing Address - Fax:407-423-2789
Practice Address - Street 1:464 N ALAFAYA TRL STE 108
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32828-4350
Practice Address - Country:US
Practice Address - Phone:407-254-2500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-21
Last Update Date:2023-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9114037363A00000X
CA55006363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty