Provider Demographics
NPI:1750072435
Name:PHEN, CAMERON
Entity type:Individual
Prefix:
First Name:CAMERON
Middle Name:
Last Name:PHEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:688 CABRA ST
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:CA
Mailing Address - Zip Code:95648-8841
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:688 CABRA ST
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:CA
Practice Address - Zip Code:95648-8841
Practice Address - Country:US
Practice Address - Phone:916-899-8386
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-15
Last Update Date:2024-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD118581223G0001X
390200000X
IL019.035342390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No1223G0001XDental ProvidersDentistGeneral Practice