Provider Demographics
NPI:1699194720
Name:CHAMPION, NIDDIA THERESA (PA- C)
Entity Type:Individual
Prefix:
First Name:NIDDIA
Middle Name:THERESA
Last Name:CHAMPION
Suffix:
Gender:F
Credentials:PA- C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:524 S CAGE BLVD STE F
Mailing Address - Street 2:
Mailing Address - City:PHARR
Mailing Address - State:TX
Mailing Address - Zip Code:78577-5448
Mailing Address - Country:US
Mailing Address - Phone:956-787-3822
Mailing Address - Fax:956-787-6061
Practice Address - Street 1:524 S CAGE BLVD STE F
Practice Address - Street 2:
Practice Address - City:PHARR
Practice Address - State:TX
Practice Address - Zip Code:78577-5448
Practice Address - Country:US
Practice Address - Phone:956-787-3822
Practice Address - Fax:956-787-6061
Is Sole Proprietor?:No
Enumeration Date:2014-04-16
Last Update Date:2016-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA08934363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX395773YLALMedicare PIN