Individual
WALLACE JACKSON CHAMPLAIN
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
DO
Contact information
Practice address
1500 E DOWNING ST STE 208, TAHLEQUAH, OK 74464-3234
(918) 456-2496
(918) 456-7108
Mailing address
1500 E DOWNING SUITE 208, TAHLEQUAH, OK 74464-3363
(918) 456-2496
(918) 456-7108
Taxonomy
Speciality
Code
Description
License number
State
207V00000X
Obstetrics & Gynecology Physician
Primary
1994
OK
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
100118860A
—
OK
Enumeration date
02/15/2006
Last updated
06/04/2019
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