Provider Demographics
NPI:1538282504
Name:CHAMPINE, ILA (PA-C, RD)
Entity Type:Individual
Prefix:
First Name:ILA
Middle Name:
Last Name:CHAMPINE
Suffix:
Gender:F
Credentials:PA-C, RD
Other - Prefix:
Other - First Name:ILA
Other - Middle Name:NICOLE
Other - Last Name:CHRISTIANSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:PO BOX 4825
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-4825
Mailing Address - Country:US
Mailing Address - Phone:360-882-2778
Mailing Address - Fax:360-604-1771
Practice Address - Street 1:2525 NE 139TH ST STE 130
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98686-2719
Practice Address - Country:US
Practice Address - Phone:360-882-2778
Practice Address - Fax:360-604-1675
Is Sole Proprietor?:No
Enumeration Date:2007-04-06
Last Update Date:2019-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA60688882363A00000X
AK192133V00000X
WADI 60680930133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2088901Medicaid