Provider Demographics
NPI:1558670588
Name:BLOOM, CAMILLE LEHUA (PA-C)
Entity type:Individual
Prefix:
First Name:CAMILLE
Middle Name:LEHUA
Last Name:BLOOM
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1804 EMBARCADERO RD
Mailing Address - Street 2:STE 100
Mailing Address - City:PALO ALTO
Mailing Address - State:CA
Mailing Address - Zip Code:94303-3341
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:725 WELCH RD
Practice Address - Street 2:
Practice Address - City:PALO ALTO
Practice Address - State:CA
Practice Address - Zip Code:94304-1601
Practice Address - Country:US
Practice Address - Phone:650-497-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-24
Last Update Date:2016-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4714363A00000X
CA53348363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant