Provider Demographics
NPI:1366599078
Name:CHARLES, THOMAS H (PA)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:H
Last Name:CHARLES
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 34584
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98124-1584
Mailing Address - Country:US
Mailing Address - Phone:509-241-7349
Mailing Address - Fax:509-241-7628
Practice Address - Street 1:4102 S REGAL ST
Practice Address - Street 2:SUITE 101
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99223-7737
Practice Address - Country:US
Practice Address - Phone:509-535-2277
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-04
Last Update Date:2008-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10000508363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8388894Medicaid
WA970027468Medicare PIN
WAGAB32948Medicare PIN
WA8388894Medicaid
WAG8872267Medicare PIN