Provider Demographics
NPI:1821603465
Name:CAMPBELL, TODD (PA-C)
Entity Type:Individual
Prefix:
First Name:TODD
Middle Name:
Last Name:CAMPBELL
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 1:3535 N FOURTH ST STE 301
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75605-0037
Mailing Address - Country:US
Mailing Address - Phone:903-234-9992
Mailing Address - Fax:
Practice Address - Street 1:1815 E 70TH ST
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-5301
Practice Address - Country:US
Practice Address - Phone:903-234-9992
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-10
Last Update Date:2020-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11768755-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant