Provider Demographics
NPI:1629017306
Name:CHAMPAGNE, SCOTT AARON (PT)
Entity Type:Individual
Prefix:MR
First Name:SCOTT
Middle Name:AARON
Last Name:CHAMPAGNE
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1219 CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:ZACHARY
Mailing Address - State:LA
Mailing Address - Zip Code:70791-2347
Mailing Address - Country:US
Mailing Address - Phone:225-658-7751
Mailing Address - Fax:225-658-7753
Practice Address - Street 1:7731 PERKINS RD
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70810-1078
Practice Address - Country:US
Practice Address - Phone:225-768-7676
Practice Address - Fax:225-768-7373
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA04324174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA4B604Medicare ID - Type Unspecified