Provider Demographics
NPI:1073697108
Name:CHAMPAGNE, JUSTIN (PA-C)
Entity Type:Individual
Prefix:MR
First Name:JUSTIN
Middle Name:
Last Name:CHAMPAGNE
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 1:134 GRANDVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06708-2507
Mailing Address - Country:US
Mailing Address - Phone:203-756-8911
Mailing Address - Fax:203-574-0548
Practice Address - Street 1:134 GRANDVIEW AVE
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06708-2507
Practice Address - Country:US
Practice Address - Phone:203-756-8911
Practice Address - Fax:203-574-0548
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2012-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001721363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q61378Medicare UPIN