Provider Demographics
NPI:1861014268
Name:CAMACHO-ALVAREZ, IOMAR A (PA-C)
Entity Type:Individual
Prefix:
First Name:IOMAR
Middle Name:A
Last Name:CAMACHO-ALVAREZ
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 1:115 E SOUTH STREET
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:MI
Mailing Address - Zip Code:49045-1228
Mailing Address - Country:US
Mailing Address - Phone:269-352-9853
Mailing Address - Fax:
Practice Address - Street 1:4777 E OUTER DR STE 1147
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48234-3241
Practice Address - Country:US
Practice Address - Phone:734-699-2900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-08
Last Update Date:2020-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601009876363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant