Provider Demographics
NPI:1639300312
Name:MODISETTE, CAMERON
Entity Type:Individual
Prefix:
First Name:CAMERON
Middle Name:
Last Name:MODISETTE
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 1:755 SCOTT CIR
Mailing Address - Street 2:
Mailing Address - City:HICKAM AFB
Mailing Address - State:HI
Mailing Address - Zip Code:96853-5399
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:755 SCOTT CIR
Practice Address - Street 2:
Practice Address - City:HICKAM AFB
Practice Address - State:HI
Practice Address - Zip Code:96853-5399
Practice Address - Country:US
Practice Address - Phone:808-448-6203
Practice Address - Fax:808-448-6226
Is Sole Proprietor?:No
Enumeration Date:2009-07-29
Last Update Date:2009-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians