Provider Demographics
NPI:1386722429
Name:CHAMPLIN, JON F (CRNA)
Entity type:Individual
Prefix:
First Name:JON
Middle Name:F
Last Name:CHAMPLIN
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 52180
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83405-2180
Mailing Address - Country:US
Mailing Address - Phone:208-523-4906
Mailing Address - Fax:208-523-2025
Practice Address - Street 1:1945 E 17TH ST
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-6429
Practice Address - Country:US
Practice Address - Phone:208-529-1945
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2007-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDRNA328A367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
P0015576OtherRAILROAD MEDICARE
ID1602114Medicare PIN