Provider Demographics
NPI:1639659279
Name:CAMERON, JUSTIN
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:CAMERON
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:PO BOX 37
Mailing Address - Street 2:
Mailing Address - City:FOSSIL
Mailing Address - State:OR
Mailing Address - Zip Code:97830-0037
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:712 JAY ST
Practice Address - Street 2:
Practice Address - City:FOSSIL
Practice Address - State:OR
Practice Address - Zip Code:97830-8371
Practice Address - Country:US
Practice Address - Phone:541-763-2725
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-14
Last Update Date:2020-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA390200000XMedicaid