Provider Demographics
NPI:1962654863
Name:COFFEE, CAMERON CLEVE (PA-C)
Entity Type:Individual
Prefix:
First Name:CAMERON
Middle Name:CLEVE
Last Name:COFFEE
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 1:700 NE 87TH AVE
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98664-1913
Mailing Address - Country:US
Mailing Address - Phone:360-882-2778
Mailing Address - Fax:360-604-1693
Practice Address - Street 1:700 NE 87TH AVE
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98664
Practice Address - Country:US
Practice Address - Phone:360-882-2778
Practice Address - Fax:360-604-1693
Is Sole Proprietor?:No
Enumeration Date:2008-10-22
Last Update Date:2018-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8541633Medicaid
WA8541633Medicaid