Provider Demographics
NPI:1386609824
Name:REGAN, CHARLES (PA-C, ATC)
Entity type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:
Last Name:REGAN
Suffix:
Gender:M
Credentials:PA-C, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 FORT ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060-3941
Mailing Address - Country:US
Mailing Address - Phone:810-987-9871
Mailing Address - Fax:810-987-6070
Practice Address - Street 1:600 FORT ST
Practice Address - Street 2:SUITE 100
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-3941
Practice Address - Country:US
Practice Address - Phone:810-987-9871
Practice Address - Fax:810-987-6070
Is Sole Proprietor?:No
Enumeration Date:2006-04-18
Last Update Date:2012-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
246Z00000X
MI5601005151363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No246Z00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, Other
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP35120071Medicare PIN