Basic Information
| Provider Information | |||||||||
| NPI: | 1104407691 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHAMPION | ||||||||
| FirstName: | SAMARA | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | MSN, APRN, NP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7834 TAYLOR RIDGE DR | ||||||||
| Address2: | |||||||||
| City: | DELTON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490467806 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6168900087 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1550 CLINTON ST | ||||||||
| Address2: | |||||||||
| City: | MUSKEGON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494425007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2317371335 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/16/2021 | ||||||||
| LastUpdateDate: | 01/02/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/02/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 4704232661 | MI | N | Allopathic & Osteopathic Physicians | Family Medicine | 363LF0000X | 4704232661NSA2109F | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 1609451905 | 05 | MI | MEDICAID | 1629066238 | 05 | MI | MEDICAID |