Provider Demographics
NPI:1205101888
Name:DORNON, CAMERON (PTA)
Entity type:Individual
Prefix:
First Name:CAMERON
Middle Name:
Last Name:DORNON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:CAMERON
Other - Middle Name:
Other - Last Name:PARKS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:1807 SHORT BRANCH DR
Mailing Address - Street 2:SUITE 103
Mailing Address - City:TRINITY
Mailing Address - State:FL
Mailing Address - Zip Code:34655-4424
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1807 SHORT BRANCH DR
Practice Address - Street 2:SUITE 103
Practice Address - City:TRINITY
Practice Address - State:FL
Practice Address - Zip Code:34655-4424
Practice Address - Country:US
Practice Address - Phone:727-372-5500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-15
Last Update Date:2013-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA22742225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant