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General NPI Number Information
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NPI Number | 1194095190
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Entity Type | Individual
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Provider Name | EARLIS RANDALL CHAMPAGNE RN
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Gender | Male
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Dates
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Enumeration Date | 01/06/2012
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Last Update Date | 01/06/2012
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Provider Practice Location Address
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Address Line | 1528 US HIGHWAY 395 N SUITE 100
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City | GARDNERVILLE
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State | NV
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Zip | 89410-5265
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Country | US
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Telephone | 775-782-3671
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Fax | 775-782-6639
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Provider Business Mailing Address
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Address Line | 1665 OLD HOT SPRINGS RD SUITE 157
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City | CARSON CITY
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State | NV
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Zip | 89706-0782
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Country | US
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Telephone | 775-687-5162
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Fax | 775-687-5745
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 163W00000X
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Taxonomy Name | Registered Nurse
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License Number | TRN 332256
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License Number State | NV
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