Provider Demographics
NPI:1588766943
Name:GAUTHIER, CHARLES D (PA-C)
Entity type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:D
Last Name:GAUTHIER
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 1:12507 POINT SMT
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78253-5270
Mailing Address - Country:US
Mailing Address - Phone:210-679-9917
Mailing Address - Fax:
Practice Address - Street 1:7400 MERTON MINTER BOULEVARD
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78284
Practice Address - Country:US
Practice Address - Phone:210-699-2149
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA 03873363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical