Provider Demographics
NPI:1215913512
Name:DECAMP, RAQUEL M (PA-C)
Entity type:Individual
Prefix:MS
First Name:RAQUEL
Middle Name:M
Last Name:DECAMP
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1838 AMERICAN WAY
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30043-6611
Mailing Address - Country:US
Mailing Address - Phone:770-995-7622
Mailing Address - Fax:770-995-7854
Practice Address - Street 1:1700 HOSPITAL SOUTH DR
Practice Address - Street 2:SUITE 302
Practice Address - City:AUSTELL
Practice Address - State:GA
Practice Address - Zip Code:30106-6810
Practice Address - Country:US
Practice Address - Phone:770-739-0999
Practice Address - Fax:678-324-4275
Is Sole Proprietor?:No
Enumeration Date:2005-12-19
Last Update Date:2019-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA004821363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA666236332GMedicaid
GA666236332FMedicaid
GA666236332CMedicaid
GA666236332DMedicaid
GA666236332EMedicaid
NE20526Medicaid
GA666236332CMedicaid
GA666236332DMedicaid
GA666236332GMedicaid