{
"Npi": {
"NPI": "1699282020",
"EntityType": "Individual",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": "Y",
"IsOrgSubpart": null,
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": null,
"LastName": "CHAMPION",
"FirstName": "DOMINIQUE",
"MiddleName": "F",
"NamePrefix": null,
"NameSuffix": null,
"Credential": "PA-C",
"OtherOrgName": null,
"OtherOrgNameTypeCode": null,
"OtherLastName": "CARLOS",
"OtherFirstName": "DOMINIQUE",
"OtherMiddleName": null,
"OtherNamePrefix": null,
"OtherNameSuffix": null,
"OtherCredential": null,
"OtherLastNameTypeCode": "1",
"FirstLineMailingAddress": "3150 N TENAYA WAY STE 260",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "LAS VEGAS",
"MailingAddressStateName": "NV",
"MailingAddressPostalCode": "89128-0459",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "702-962-5920",
"MailingAddressFaxNumber": null,
"FirstLinePracticeLocationAddress": "3150 N TENAYA WAY STE 260",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "LAS VEGAS",
"PracticeLocationAddressStateName": "NV",
"PracticeLocationAddressPostalCode": "89128-0459",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "702-962-5920",
"PracticeLocationAddressFaxNumber": "702-240-9984",
"EnumerationDate": "01/08/2018",
"LastUpdateDate": "12/11/2024",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": "F",
"Gender": "Female",
"AuthorizedOfficialLastName": null,
"AuthorizedOfficialFirstName": null,
"AuthorizedOfficialMiddleName": null,
"AuthorizedOfficialTitle": null,
"AuthorizedOfficialNamePrefix": null,
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": null,
"AuthorizedOfficialTelephoneNumber": null,
"Taxonomies": {
"Taxonomy": [
{
"TaxonomyCode": "363AS0400X",
"TaxonomyName": "Surgical Physician Assistant",
"LicenseNumber": "PA-1334",
"LicenseNumberStateCode": "AR",
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "363AS0400X",
"TaxonomyName": "Surgical Physician Assistant",
"LicenseNumber": "10004488A",
"LicenseNumberStateCode": "IN",
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "363A00000X",
"TaxonomyName": "Physician Assistant",
"LicenseNumber": "PA1929",
"LicenseNumberStateCode": "NV",
"PrimaryTaxonomySwitch": "Y"
}
]
},
"HealthcareProviderTaxonomyGroups": null
}
}