Provider Demographics
NPI:1295254936
Name:CAMPOS, JONATHAN MARC
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:MARC
Last Name:CAMPOS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:265 WAKEFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89183-5155
Mailing Address - Country:US
Mailing Address - Phone:808-227-4401
Mailing Address - Fax:
Practice Address - Street 1:265 WAKEFIELD AVE
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89183-5155
Practice Address - Country:US
Practice Address - Phone:808-227-4401
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-13
Last Update Date:2025-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty