Provider Demographics
NPI:1497033187
Name:CHAMPION, SHANE
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:
Last Name:CHAMPION
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5500 DARA LN
Mailing Address - Street 2:
Mailing Address - City:GRAND BAY
Mailing Address - State:AL
Mailing Address - Zip Code:36541-3465
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5500 DARA LN
Practice Address - Street 2:
Practice Address - City:GRAND BAY
Practice Address - State:AL
Practice Address - Zip Code:36541-3465
Practice Address - Country:US
Practice Address - Phone:251-454-1897
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-28
Last Update Date:2011-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPTA3404225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant