MEDICARE: EMMA S CHAMPLIN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program
2	363A00000X	Physician Assistant	1187107

General Provider Information

NPI Number	:	1386223717
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EMMA S CHAMPLIN

Provider Business Mailing Address
First Line	:	1794 W 48TH ST
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44102-3416
Country	:	US
Telephone Number	:	561-346-0014
Fax Number	:

Provider Business Practice Location Address
First Line	:	1794 W 48TH ST
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44102-3416
Country	:	US
Telephone Number	:	561-346-0014
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/04/2021
Last Update Date	:	06/14/2021

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Directions to “ EMMA S CHAMPLIN ” Practice Location

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