Provider Demographics
NPI:1386920197
Name:COFFARO, CHARLES G (PA-C)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:G
Last Name:COFFARO
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 E BUSINESS WAY
Mailing Address - Street 2:SUITE A
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45241-2374
Mailing Address - Country:US
Mailing Address - Phone:513-354-3700
Mailing Address - Fax:513-354-7651
Practice Address - Street 1:500 E BUSINESS WAY
Practice Address - Street 2:SUITE A
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45241-2374
Practice Address - Country:US
Practice Address - Phone:513-354-3700
Practice Address - Fax:513-354-7651
Is Sole Proprietor?:No
Enumeration Date:2011-10-25
Last Update Date:2013-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYTC057363A00000X
OH003396363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2714110Medicaid
OH2714110Medicaid