Provider Demographics
NPI:1194702712
Name:CADDY, CHARLES II (RPA-C)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:CADDY
Suffix:II
Gender:M
Credentials:RPA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:485 N KS HWY 2
Mailing Address - Street 2:
Mailing Address - City:ANTHONY
Mailing Address - State:KS
Mailing Address - Zip Code:67003-2526
Mailing Address - Country:US
Mailing Address - Phone:620-914-1200
Mailing Address - Fax:620-914-1256
Practice Address - Street 1:485 N KS HWY 2
Practice Address - Street 2:
Practice Address - City:ANTHONY
Practice Address - State:KS
Practice Address - Zip Code:67003-2526
Practice Address - Country:US
Practice Address - Phone:620-914-1200
Practice Address - Fax:620-914-1256
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-23
Last Update Date:2020-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1500771363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100407220EMedicaid
KS427149Medicare PIN
S53685Medicare UPIN