Provider Demographics
NPI:1184673741
Name:RAINES, CAMILLA A (PA)
Entity Type:Individual
Prefix:MS
First Name:CAMILLA
Middle Name:A
Last Name:RAINES
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:3205 N ACADEMY BLVD
Mailing Address - Street 2:SUITE 130
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80917-5101
Mailing Address - Country:US
Mailing Address - Phone:719-632-5700
Mailing Address - Fax:719-344-7837
Practice Address - Street 1:2828 INTERNATIONAL CIR
Practice Address - Street 2:SUITE 140
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80910-3127
Practice Address - Country:US
Practice Address - Phone:719-632-5700
Practice Address - Fax:719-344-7821
Is Sole Proprietor?:No
Enumeration Date:2006-05-09
Last Update Date:2014-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA-644363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO16830351Medicaid