Provider Demographics
NPI:1063568905
Name:PINKSTON, CHARLES ENZIO (PA)
Entity type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:ENZIO
Last Name:PINKSTON
Suffix:
Gender:M
Credentials:PA
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 3685
Mailing Address - Street 2:
Mailing Address - City:CERRITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90703-3685
Mailing Address - Country:US
Mailing Address - Phone:562-500-4644
Mailing Address - Fax:626-350-5801
Practice Address - Street 1:1532 SAN BERNARDINO AVE
Practice Address - Street 2:SUITE CA2
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91767-3559
Practice Address - Country:US
Practice Address - Phone:909-624-0392
Practice Address - Fax:909-624-0984
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA14875363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant