Provider Demographics
NPI:1104418458
Name:CAMACHO, LUIS FELIPE
Entity type:Individual
Prefix:
First Name:LUIS
Middle Name:FELIPE
Last Name:CAMACHO
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 1:315 W 15TH ST
Mailing Address - Street 2:
Mailing Address - City:LIBERAL
Mailing Address - State:KS
Mailing Address - Zip Code:67901-2455
Mailing Address - Country:US
Mailing Address - Phone:620-624-1651
Mailing Address - Fax:620-629-6523
Practice Address - Street 1:305 W 15TH ST STE 102
Practice Address - Street 2:
Practice Address - City:LIBERAL
Practice Address - State:KS
Practice Address - Zip Code:67901-2455
Practice Address - Country:US
Practice Address - Phone:620-417-7578
Practice Address - Fax:680-417-7577
Is Sole Proprietor?:No
Enumeration Date:2021-02-08
Last Update Date:2024-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS82969363LF0000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS82969OtherKANSAS STATE LICENSE