Provider Demographics
NPI:1922876085
Name:GOMES XAVIER HOLLAND, CAMILLA
Entity type:Individual
Prefix:
First Name:CAMILLA
Middle Name:
Last Name:GOMES XAVIER HOLLAND
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CAMILLA
Other - Middle Name:
Other - Last Name:GOMES XAVIER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 20800
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-4105
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:16215 S JOG RD STE 100
Practice Address - Street 2:
Practice Address - City:DELRAY BEACH
Practice Address - State:FL
Practice Address - Zip Code:33446-2387
Practice Address - Country:US
Practice Address - Phone:561-303-0013
Practice Address - Fax:567-499-3199
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-18
Last Update Date:2024-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9118289363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant