WALLACE JACKSON CHAMPLAIN (DO) – Obstetrics & Gynecology Physician, NPI 1689648636
Obstetrics & Gynecology Physician
Main info
Doctor Profile
Profile Insights
NPPES metrics only — not quality of care.
Provider Addresses for WALLACE JACKSON CHAMPLAIN (DO)
127 E Main
Hulbert, OK 74441
Phone: (918) 772-3390
Fax: (918) 772-3638
Type: Location
208, East Downing Street, Tahlequah, Cherokee County, Oklahoma, 74464, United States
TAHLEQUAH, OK 744643234
Phone: (918) 456-2496
Fax: (918) 456-7108
Type: Location
1500 E DOWNING SUITE 208
TAHLEQUAH, OK 744643363
Phone: (918) 456-2496
Fax: (918) 456-7108
Type: Mailing
NPPES updates history
No NPPES updates recorded for this provider.
Prescription Activity
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Open Payments (CMS)
No Open Payments data available for this provider.
This can happen when there are no reportable CMS Open Payments records.
Medicare Enrollment & Revalidation
Source: CMS public data · Not endorsed by CMS ·
Educational use only—not medical, billing, or legal advice.
PECOS enrollment status
Participating (accepts Medicare assignment)
Enrollment effective: 2004-05-20
PECOS data refreshed: 2026-06-15
Medicare revalidation (CMS due date list)
Due date not assigned yet
CMS is tracking this Medicare enrollment for revalidation, but has not published a due date.
Enrollment records
1
Earliest due date
Not assigned (TBD)
CMS data updated
2026-06-01
Revalidation progress
- Medicare enrolled
- On CMS revalidation list
- Due date assigned
- Revalidate in PECOS
CMS enrollment records
| Enrollment ID | Type | Specialty | State | Due date |
|---|---|---|---|---|
| I20040520000836 | I | Obstetrics/Gynecology | OK | TBD |
What to do next
- No action required while the due date shows TBD.
- Check the CMS Revalidation Lookup Tool periodically — CMS updates the list about every 60 days.
- Do not submit a revalidation application in PECOS until CMS publishes a concrete due date.
Prepare CMS-855 application → · Look up this NPI in PECOS → · Verify on CMS PECOS
Medicare Utilization (FFS)
Source: CMS public data · Not endorsed by CMS · Beneficiary counts under 11 are suppressed in source data ·
Educational use only—not medical, billing, or legal advice.
No Medicare fee-for-service utilization data available for this provider in our database.
Insurance plans in this area (ZIP 74441)
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Group practice members
| Name | Specialty | State |
|---|---|---|
| Nurse Practitioner | OK | |
| Nurse Practitioner | OK | |
| Family Practice, Internal Medicine | OK | |
| Nurse Practitioner | OK | |
| Nurse Practitioner | OK | |
| Nurse Practitioner | OK | |
| Physician Assistant | OK | |
| Nurse Practitioner | OK | |
| O B S T E T R I C S/ G Y N E C O L O G Y | NY | |
| Nurse Practitioner | OK |
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