Provider Demographics
NPI:1699282020
Name:CHAMPION, DOMINIQUE F (PA-C)
Entity type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:F
Last Name:CHAMPION
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:DOMINIQUE
Other - Middle Name:
Other - Last Name:CARLOS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3150 N TENAYA WAY STE 260
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89128-0459
Mailing Address - Country:US
Mailing Address - Phone:702-962-5920
Mailing Address - Fax:
Practice Address - Street 1:3150 N TENAYA WAY STE 260
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89128-0459
Practice Address - Country:US
Practice Address - Phone:702-962-5920
Practice Address - Fax:702-240-9984
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-08
Last Update Date:2024-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPA-1334363AS0400X
IN10004488A363AS0400X
NVPA1929363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Single Specialty