Provider Demographics
NPI:1053886697
Name:CHRISTIE, CAMERON (PA-C)
Entity type:Individual
Prefix:
First Name:CAMERON
Middle Name:
Last Name:CHRISTIE
Suffix:
Gender:M
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 1:1040 W IMPERIAL HWY
Mailing Address - Street 2:
Mailing Address - City:LA HABRA
Mailing Address - State:CA
Mailing Address - Zip Code:90631-0608
Mailing Address - Country:US
Mailing Address - Phone:714-451-1072
Mailing Address - Fax:
Practice Address - Street 1:1040 W IMPERIAL HWY
Practice Address - Street 2:
Practice Address - City:LA HABRA
Practice Address - State:CA
Practice Address - Zip Code:90631-0608
Practice Address - Country:US
Practice Address - Phone:714-451-1072
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-10
Last Update Date:2021-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA57596363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA57596OtherCALIFORNIA PHYSICIAN ASSISTANT LICENSE NUMBER