Provider Demographics
NPI:1548800774
Name:CAMODY, AMBER MARIE
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:MARIE
Last Name:CAMODY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:441 THE 25 WAY NE
Mailing Address - Street 2:UNIT 150
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109
Mailing Address - Country:US
Mailing Address - Phone:505-332-5800
Mailing Address - Fax:
Practice Address - Street 1:4411 THE 25 WAY NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-5857
Practice Address - Country:US
Practice Address - Phone:505-332-5800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-15
Last Update Date:2021-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NMPA2021-0041363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program