Provider Demographics
NPI:1497084198
Name:CAMACHO, LANCE WILLIAM (PA-C)
Entity Type:Individual
Prefix:
First Name:LANCE
Middle Name:WILLIAM
Last Name:CAMACHO
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4102 PINION DR
Mailing Address - Street 2:
Mailing Address - City:USAF ACADEMY
Mailing Address - State:CO
Mailing Address - Zip Code:80840-2502
Mailing Address - Country:US
Mailing Address - Phone:719-333-6054
Mailing Address - Fax:
Practice Address - Street 1:4102 PINION DR
Practice Address - Street 2:
Practice Address - City:UNITED STATES AIR FORCE ACAD
Practice Address - State:CO
Practice Address - Zip Code:80840-2502
Practice Address - Country:US
Practice Address - Phone:719-333-6054
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-09
Last Update Date:2021-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9109563363AM0700X
TXPA08575363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical