Provider Demographics
NPI:1689654659
Name:CHAMPEAU, MATTHEW (PA)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:CHAMPEAU
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2699
Mailing Address - Street 2:DEPT 200
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06146-2699
Mailing Address - Country:US
Mailing Address - Phone:866-898-7138
Mailing Address - Fax:616-975-9824
Practice Address - Street 1:41 BREWSTER RD
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:CT
Practice Address - Zip Code:06010-5161
Practice Address - Country:US
Practice Address - Phone:860-585-3000
Practice Address - Fax:860-585-3907
Is Sole Proprietor?:No
Enumeration Date:2006-01-18
Last Update Date:2007-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001690363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
970002481Medicare PIN
Q58216Medicare UPIN
CT970002012Medicare ID - Type Unspecified