Basic Information
| Provider Information | |||||||||
| NPI: | 1487807384 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CAMERON | ||||||||
| FirstName: | LAUREE | ||||||||
| MiddleName: | DANIELLE | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 363 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | LEWISVILLE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750573867 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9724364434 | ||||||||
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| Practice Location | |||||||||
| Address1: | 9430 PARK WEST BLVD STE 130 | ||||||||
| Address2: | |||||||||
| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 379234205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8656904861 | ||||||||
| FaxNumber: | 8655608525 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/23/2008 | ||||||||
| LastUpdateDate: | 07/01/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/01/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 1150 | TN | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363AS0400X | 1150 | TN | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363A00000X | 1150 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 1509729 | 05 | TN | MEDICAID | P00691294 | 01 | RR MEDICARE | OTHER |