Provider Demographics
NPI:1710944681
Name:CHAMPION, ARCHIE JOEL III (PA-C)
Entity Type:Individual
Prefix:MR
First Name:ARCHIE
Middle Name:JOEL
Last Name:CHAMPION
Suffix:III
Gender:M
Credentials:PA-C
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Mailing Address - Street 1:3301 FIRST STREET EAST
Mailing Address - Street 2:SUITE A
Mailing Address - City:VIDALIA
Mailing Address - State:GA
Mailing Address - Zip Code:30474
Mailing Address - Country:US
Mailing Address - Phone:912-537-4411
Mailing Address - Fax:912-538-8485
Practice Address - Street 1:3301 FIRST STREET EAST
Practice Address - Street 2:SUITE A
Practice Address - City:VIDALIA
Practice Address - State:GA
Practice Address - Zip Code:30474
Practice Address - Country:US
Practice Address - Phone:912-537-4411
Practice Address - Fax:912-538-8485
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2010-07-29
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Provider Licenses
StateLicense IDTaxonomies
GA003747363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA019893311AMedicaid
GAP50572Medicare UPIN
GA97WCDXDMedicare ID - Type Unspecified