Provider Demographics
NPI:1659866119
Name:LANDRETH, CAMERON TRACE (PA-C)
Entity Type:Individual
Prefix:
First Name:CAMERON
Middle Name:TRACE
Last Name:LANDRETH
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12000 HUEBNER RD STE 204
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78230-1213
Mailing Address - Country:US
Mailing Address - Phone:210-561-2422
Mailing Address - Fax:210-561-2466
Practice Address - Street 1:12000 HUEBNER RD STE 104
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78230-1209
Practice Address - Country:US
Practice Address - Phone:210-561-2422
Practice Address - Fax:210-561-2466
Is Sole Proprietor?:No
Enumeration Date:2018-06-27
Last Update Date:2019-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA12024207Q00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine