Provider Demographics
NPI:1740538891
Name:CAMPOS, MICHELLE LEMOYNE (PA-C)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:LEMOYNE
Last Name:CAMPOS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:LEMOYNE
Other - Last Name:BAUER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:401 BICENTENNIAL WAY SUITE 120 MOB1
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95403-2149
Mailing Address - Country:US
Mailing Address - Phone:916-812-3104
Mailing Address - Fax:707-573-5421
Practice Address - Street 1:401 BICENTENNIAL WAY SUITE 120 MOB1
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403-2149
Practice Address - Country:US
Practice Address - Phone:916-812-3104
Practice Address - Fax:707-573-5421
Is Sole Proprietor?:No
Enumeration Date:2012-08-21
Last Update Date:2022-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA 22420363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0095420Medicaid