Provider Demographics
NPI:1508807520
Name:CAMP, TOMMY DEAN (PA)
Entity Type:Individual
Prefix:
First Name:TOMMY
Middle Name:DEAN
Last Name:CAMP
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1101 NW 178TH ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73012-4281
Mailing Address - Country:US
Mailing Address - Phone:405-285-2161
Mailing Address - Fax:405-726-8277
Practice Address - Street 1:1101 NW 178TH ST
Practice Address - Street 2:SUITE B
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73012-4281
Practice Address - Country:US
Practice Address - Phone:405-285-2161
Practice Address - Fax:405-726-8277
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2020-04-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OK880363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1002275AMedicaid
OK243801001Medicare PIN
OK1002275AMedicaid