Basic Information
| Provider Information | |||||||||
| NPI: | 1629631320 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PAGE | ||||||||
| FirstName: | KAMERON | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1995 TECHNOLOGY PKWY | ||||||||
| Address2: | |||||||||
| City: | MECHANICSBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 170508522 | ||||||||
| CountryCode: | US | ||||||||
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| Address1: | 1995 TECHNOLOGY PKWY | ||||||||
| Address2: | |||||||||
| City: | MECHANICSBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 170508522 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7172318772 | ||||||||
| FaxNumber: | 7172318435 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/17/2019 | ||||||||
| LastUpdateDate: | 04/15/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 04/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | MA060676 | PA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 390200000X | NC | N | 193400000X SINGLE SPECIALTY GROUP | Student, Health Care | Student in an Organized Health Care Education/Training Program | 363A00000X | OA004857 | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 103660017 | 05 | PA | MEDICAID |