Provider Demographics
NPI:1063978401
Name:SMITH, CHARLES
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:419 BROWN AVE
Mailing Address - Street 2:
Mailing Address - City:GREENSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:15601-2251
Mailing Address - Country:US
Mailing Address - Phone:864-872-9571
Mailing Address - Fax:
Practice Address - Street 1:828 W MAIN ST
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:PA
Practice Address - Zip Code:15666-1730
Practice Address - Country:US
Practice Address - Phone:724-547-4441
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-11
Last Update Date:2019-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA060536363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant