Provider Demographics
NPI:1598902546
Name:CHAMPAGNE, EDWIN J (MED, ATC, LAT)
Entity Type:Individual
Prefix:MR
First Name:EDWIN
Middle Name:J
Last Name:CHAMPAGNE
Suffix:
Gender:M
Credentials:MED, ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7173 FM 1628
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78263-9671
Mailing Address - Country:US
Mailing Address - Phone:210-649-2951
Mailing Address - Fax:210-581-1357
Practice Address - Street 1:7173 FM 1628
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78263-9671
Practice Address - Country:US
Practice Address - Phone:210-581-1181
Practice Address - Fax:210-581-1357
Is Sole Proprietor?:No
Enumeration Date:2009-01-13
Last Update Date:2015-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT25382255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer