Provider Demographics
NPI:1457970519
Name:PELLETIER, CAMERON (DPT)
Entity type:Individual
Prefix:DR
First Name:CAMERON
Middle Name:
Last Name:PELLETIER
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3402 BIXLER DR APT 204
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88012-5108
Mailing Address - Country:US
Mailing Address - Phone:843-576-9054
Mailing Address - Fax:
Practice Address - Street 1:3402 BIXLER DR APT 204
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88012-5108
Practice Address - Country:US
Practice Address - Phone:843-576-9054
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-09
Last Update Date:2020-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM5585225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist