Provider Demographics
NPI:1336713254
Name:CHAMPION, BROOKE DAVIS (PA-C)
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:DAVIS
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 1:95 FALL HARVEST CT
Mailing Address - Street 2:
Mailing Address - City:FRANKLINTON
Mailing Address - State:NC
Mailing Address - Zip Code:27525-8450
Mailing Address - Country:US
Mailing Address - Phone:919-616-8570
Mailing Address - Fax:
Practice Address - Street 1:8331 BANDFORD WAY STE 101
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27615-2765
Practice Address - Country:US
Practice Address - Phone:919-841-4566
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-15
Last Update Date:2022-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-11889363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant