Provider Demographics
NPI:1992123384
Name:WILLSON, CAMILLA
Entity type:Individual
Prefix:
First Name:CAMILLA
Middle Name:
Last Name:WILLSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:649 GETTYSBURG ST
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15206-4549
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1620 PENNSYLVANIA AVE STE A
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94533-3509
Practice Address - Country:US
Practice Address - Phone:707-426-5644
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-02
Last Update Date:2021-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE5464213ES0103X
PASC006560213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery