Provider Demographics
NPI:1306451851
Name:OATES, CHARLESTON GAVIN (PTA)
Entity type:Individual
Prefix:MR
First Name:CHARLESTON
Middle Name:GAVIN
Last Name:OATES
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5719 RAINBOW RD
Mailing Address - Street 2:
Mailing Address - City:COVE
Mailing Address - State:TX
Mailing Address - Zip Code:77523-5071
Mailing Address - Country:US
Mailing Address - Phone:501-333-4040
Mailing Address - Fax:
Practice Address - Street 1:5719 RAINBOW RD
Practice Address - Street 2:
Practice Address - City:COVE
Practice Address - State:TX
Practice Address - Zip Code:77523-5071
Practice Address - Country:US
Practice Address - Phone:501-333-4040
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-11
Last Update Date:2020-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2141867225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant