Provider Demographics
NPI:1194747808
Name:CAMPBELL, LORRAINE DOME (PAC)
Entity type:Individual
Prefix:
First Name:LORRAINE
Middle Name:DOME
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3400 DATA DR
Mailing Address - Street 2:PHYSICIAN SUPPORT SERVICES - 2ND FL
Mailing Address - City:RANCHO CORDOVA
Mailing Address - State:CA
Mailing Address - Zip Code:95670-7956
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3838 SAN DIMAS ST
Practice Address - Street 2:SUITE A200
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93301-2284
Practice Address - Country:US
Practice Address - Phone:661-654-0200
Practice Address - Fax:661-664-2855
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2014-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA14728363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG476810OtherMEDICAL/BKFD INT MED/DOUG
CAG476810OtherMEDICAL/BKFD INT MED/DOUG