Basic Information
Provider Information | |||||||||
NPI: | 1366400699 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CHAMPLIN | ||||||||
FirstName: | PATRICIA | ||||||||
MiddleName: | J | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | ANP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | CHAMPLIN CZUMAJ | ||||||||
OtherFirstName: | PATRICIA | ||||||||
OtherMiddleName: | J | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 800 CARTER STREET | ||||||||
Address2: | ATTN KELLY STEELE | ||||||||
City: | ROCHESTER | ||||||||
State: | NY | ||||||||
PostalCode: | 14621 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5853394793 | ||||||||
FaxNumber: | 5853364845 | ||||||||
Practice Location | |||||||||
Address1: | 120 GARDENVILLE PKWY W | ||||||||
Address2: |   | ||||||||
City: | WEST SENECA | ||||||||
State: | NY | ||||||||
PostalCode: | 14224 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7166683600 | ||||||||
FaxNumber: | 7166064003 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/03/2006 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 300246 | NY | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   |
ID Information
ID | Type | State | Issuer | Description | 10767064 | 01 | NY | CAQH | OTHER | 9513172 | 01 | NY | IHA | OTHER | P00189067 | 01 | NY | MEDICARE RAILROAD | OTHER | 000560338004 | 01 | NY | BCBS | OTHER | 159955BJ | 01 | NY | PREFERRED CARE | OTHER | 040511000506 | 01 | NY | FIDELIS | OTHER |