Provider Demographics
NPI:1770266314
Name:CHAMPAGNE, TAYLOR
Entity type:Individual
Prefix:
First Name:TAYLOR
Middle Name:
Last Name:CHAMPAGNE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 CONWAY CT APT 2E
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:NY
Mailing Address - Zip Code:12180-2166
Mailing Address - Country:US
Mailing Address - Phone:518-306-8428
Mailing Address - Fax:
Practice Address - Street 1:767 TROY SCHENECTADY RD # 1
Practice Address - Street 2:
Practice Address - City:LATHAM
Practice Address - State:NY
Practice Address - Zip Code:12110-2446
Practice Address - Country:US
Practice Address - Phone:518-690-7020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-10
Last Update Date:2023-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009879-01152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist