Basic Information
| Provider Information | |||||||||
| NPI: | 1396109823 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHAMPLIN | ||||||||
| FirstName: | GRACE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KIRKPATRICK | ||||||||
| OtherFirstName: | GRACE | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4444 E 41ST ST | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741352527 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9186194300 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4444 E 41ST ST | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741352527 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9186194300 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/11/2016 | ||||||||
| LastUpdateDate: | 10/04/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/04/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | T3052 | TX | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | MD0000056735 | TN | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | 56735 | TN | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | 39918 | OK | Y | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.