Provider Demographics
NPI:1316062573
Name:WALBOURN, CHARLES (PA)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:WALBOURN
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 1:3200 AVENUE E
Mailing Address - Street 2:
Mailing Address - City:HONDO
Mailing Address - State:TX
Mailing Address - Zip Code:78861
Mailing Address - Country:US
Mailing Address - Phone:830-426-7444
Mailing Address - Fax:830-426-7468
Practice Address - Street 1:3200 AVENUE E
Practice Address - Street 2:
Practice Address - City:HONDO
Practice Address - State:TX
Practice Address - Zip Code:78861
Practice Address - Country:US
Practice Address - Phone:830-426-7444
Practice Address - Fax:830-426-7468
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA00820363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8K5352OtherBLUECROSS
TX8G3322OtherBLUECROSS
TX8J0362OtherBLUECROSS
TX86807KMedicare ID - Type Unspecified
TX451330Medicare ID - Type Unspecified
TX8K5352OtherBLUECROSS
TXHR12Medicare ID - Type Unspecified
TX86800KMedicare ID - Type Unspecified
TX8G4237Medicare ID - Type Unspecified
TX8C8723Medicare ID - Type Unspecified