Basic Information
| Provider Information | |||||||||
| NPI: | 1992756308 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHAMPEAU | ||||||||
| FirstName: | COREY | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | P.A. | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | RICE | ||||||||
| OtherFirstName: | COREY | ||||||||
| OtherMiddleName: | A | ||||||||
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| OtherCredential: | PA | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 65 KANE ST | ||||||||
| Address2: | PROVIDER ENROLLMENT - ELLIE ATKINS | ||||||||
| City: | WEST HARTFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 061192110 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8605236421 | ||||||||
| FaxNumber: | 8605233701 | ||||||||
| Practice Location | |||||||||
| Address1: | 263 FARMINGTON AVE | ||||||||
| Address2: | NEONATOLOGY | ||||||||
| City: | FARMINGTON | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060302948 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8606793105 | ||||||||
| FaxNumber: | 8606791403 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/12/2006 | ||||||||
| LastUpdateDate: | 04/20/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 001691 | CT | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.