Provider Demographics
NPI:1063947257
Name:CAMPOS, PAUL NICHOLAS (PTA)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:NICHOLAS
Last Name:CAMPOS
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:812 S MAGNOLIA ST
Mailing Address - Street 2:
Mailing Address - City:ROCKPORT
Mailing Address - State:TX
Mailing Address - Zip Code:78382-2438
Mailing Address - Country:US
Mailing Address - Phone:361-205-4303
Mailing Address - Fax:
Practice Address - Street 1:812 S MAGNOLIA ST
Practice Address - Street 2:
Practice Address - City:ROCKPORT
Practice Address - State:TX
Practice Address - Zip Code:78382-2438
Practice Address - Country:US
Practice Address - Phone:361-205-4303
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-25
Last Update Date:2017-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2121623225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant