Provider Demographics
NPI:1407241300
Name:CHAMPION, GWENDOLYN (LSA)
Entity Type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:
Last Name:CHAMPION
Suffix:
Gender:F
Credentials:LSA
Other - Prefix:
Other - First Name:GWENDOLYN
Other - Middle Name:
Other - Last Name:SCOTT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LSA
Mailing Address - Street 1:4026 E TEAL ESTATES CIR
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:TX
Mailing Address - Zip Code:77545-8851
Mailing Address - Country:US
Mailing Address - Phone:510-984-8610
Mailing Address - Fax:
Practice Address - Street 1:4026 E TEAL ESTATES CIR
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:TX
Practice Address - Zip Code:77545
Practice Address - Country:US
Practice Address - Phone:510-984-8610
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-30
Last Update Date:2020-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SA00547363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1407241300OtherINSURANCE COMPANIES