Provider Demographics
NPI:1689100646
Name:MUSTAIN, CAMERON (DOM, LAC)
Entity Type:Individual
Prefix:DR
First Name:CAMERON
Middle Name:
Last Name:MUSTAIN
Suffix:
Gender:M
Credentials:DOM, LAC
Other - Prefix:DR
Other - First Name:CHILAN
Other - Middle Name:
Other - Last Name:MUSTAIN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DOM, LAC
Mailing Address - Street 1:6440 E BROADWAY BLVD
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85710-3504
Mailing Address - Country:US
Mailing Address - Phone:520-881-0827
Mailing Address - Fax:
Practice Address - Street 1:6440 E BROADWAY BLVD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85710-3504
Practice Address - Country:US
Practice Address - Phone:520-881-0827
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-11
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ0951171100000X
NM1168171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist