Provider Demographics
NPI:1154456788
Name:PHILLIPS, CAMERON (LMT)
Entity Type:Individual
Prefix:
First Name:CAMERON
Middle Name:
Last Name:PHILLIPS
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 KRESKY AVE STE J
Mailing Address - Street 2:
Mailing Address - City:CENTRALIA
Mailing Address - State:WA
Mailing Address - Zip Code:98531-3794
Mailing Address - Country:US
Mailing Address - Phone:360-736-1191
Mailing Address - Fax:360-736-1192
Practice Address - Street 1:1000 KRESKY AVE STE J
Practice Address - Street 2:
Practice Address - City:CENTRALIA
Practice Address - State:WA
Practice Address - Zip Code:98531-3794
Practice Address - Country:US
Practice Address - Phone:360-736-1191
Practice Address - Fax:360-736-1192
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00010009174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist