Provider Demographics
NPI:1598729071
Name:CAMACHO-STOVERN, LETICIA (PA-C)
Entity Type:Individual
Prefix:
First Name:LETICIA
Middle Name:
Last Name:CAMACHO-STOVERN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:LETICIA
Other - Middle Name:
Other - Last Name:CAMACHO-MOJICA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:69 LEBER AVE
Mailing Address - Street 2:
Mailing Address - City:CARTERET
Mailing Address - State:NJ
Mailing Address - Zip Code:07008-1942
Mailing Address - Country:US
Mailing Address - Phone:386-747-6007
Mailing Address - Fax:
Practice Address - Street 1:5141 BROADWAY
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10034-1159
Practice Address - Country:US
Practice Address - Phone:212-932-4171
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-13
Last Update Date:2023-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA3045363A00000X
NY004975-01363A00000X
NJ25MP00739700363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL00099239Medicare ID - Type UnspecifiedMEDICARE NO
FLE0717ZMedicare UPIN
FLPENDINGMedicare PIN
FLE0717YMedicare PIN