Provider Demographics
NPI:1992299655
Name:WOODBURN-CAMP, PRESTON
Entity type:Individual
Prefix:DR
First Name:PRESTON
Middle Name:
Last Name:WOODBURN-CAMP
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 1:150 MEMORIAL DR # A
Mailing Address - Street 2:
Mailing Address - City:KINGWOOD
Mailing Address - State:WV
Mailing Address - Zip Code:26537-1141
Mailing Address - Country:US
Mailing Address - Phone:304-329-1400
Mailing Address - Fax:
Practice Address - Street 1:150 MEMORIAL DR # A
Practice Address - Street 2:
Practice Address - City:KINGWOOD
Practice Address - State:WV
Practice Address - Zip Code:26537-1141
Practice Address - Country:US
Practice Address - Phone:304-329-1400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-18
Last Update Date:2024-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR232184367500000X
WV79305367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered