Healthcare Provider Details

I. General information

NPI: 1699282020
Provider Name (Legal Business Name): DOMINIQUE F CHAMPION PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: DOMINIQUE CARLOS

II. Dates (important events)

Enumeration Date: 01/08/2018
Last Update Date: 12/11/2024
Certification Date: 12/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3150 N TENAYA WAY STE 260
LAS VEGAS NV
89128-0459
US

IV. Provider business mailing address

3150 N TENAYA WAY STE 260
LAS VEGAS NV
89128-0459
US

V. Phone/Fax

Practice location:
  • Phone: 702-962-5920
  • Fax: 702-240-9984
Mailing address:
  • Phone: 702-962-5920
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA-1334
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number10004488A
License Number StateIN
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA1929
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: