Provider Demographics
NPI:1164424594
Name:CAMENISCH, MARCI (PAC)
Entity Type:Individual
Prefix:
First Name:MARCI
Middle Name:
Last Name:CAMENISCH
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 6TH ST
Mailing Address - Street 2:
Mailing Address - City:TAFT
Mailing Address - State:CA
Mailing Address - Zip Code:93268-2704
Mailing Address - Country:US
Mailing Address - Phone:661-763-5131
Mailing Address - Fax:667-763-5137
Practice Address - Street 1:1479 W LACEY BLVD
Practice Address - Street 2:
Practice Address - City:HANFORD
Practice Address - State:CA
Practice Address - Zip Code:93230-5906
Practice Address - Country:US
Practice Address - Phone:559-583-4617
Practice Address - Fax:559-583-4625
Is Sole Proprietor?:No
Enumeration Date:2005-08-15
Last Update Date:2014-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA13244363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAR23504Medicare UPIN