Healthcare Provider Details

I. General information

NPI: 1083192496
Provider Name (Legal Business Name): RAYMOND J CHAMPAGNE II M.ED., LAT, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/30/2018
Last Update Date: 07/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PENN STATE SPORTS MEDICINE 109 LASCH BUILDING
UNIVERSITY PARK PA
16802
US

IV. Provider business mailing address

183 FAITH CIRCLE
BOALSBURG PA
16827
US

V. Phone/Fax

Practice location:
  • Phone: 985-860-2876
  • Fax:
Mailing address:
  • Phone: 985-860-2876
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: