Provider Demographics
NPI:1336589241
Name:CAMPOS, MARC T (PA-C)
Entity Type:Individual
Prefix:
First Name:MARC
Middle Name:T
Last Name:CAMPOS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:330 N WABASH
Mailing Address - Street 2:G20
Mailing Address - City:MARION
Mailing Address - State:IN
Mailing Address - Zip Code:46952-2600
Mailing Address - Country:US
Mailing Address - Phone:765-660-7600
Mailing Address - Fax:765-651-7313
Practice Address - Street 1:1103 N BALDWIN AVENUE
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IN
Practice Address - Zip Code:46952-2536
Practice Address - Country:US
Practice Address - Phone:765-660-7480
Practice Address - Fax:765-382-4495
Is Sole Proprietor?:No
Enumeration Date:2013-06-25
Last Update Date:2019-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN363A00000X
CT4367363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN00001216651OtherANTHEM