Healthcare Provider Details

I. General information

NPI: 1073697108
Provider Name (Legal Business Name): JUSTIN CHAMPAGNE PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/25/2006
Last Update Date: 01/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

134 GRANDVIEW AVE
WATERBURY CT
06708-2507
US

IV. Provider business mailing address

134 GRANDVIEW AVE
WATERBURY CT
06708-2507
US

V. Phone/Fax

Practice location:
  • Phone: 203-756-8911
  • Fax: 203-574-0548
Mailing address:
  • Phone: 203-756-8911
  • Fax: 203-574-0548

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number001721
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number001721
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: