Provider Demographics
NPI:1699702662
Name:WORLEY, CHARLES B (PA-C)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:B
Last Name:WORLEY
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3725 MIDVALE AVE #4
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90034
Mailing Address - Country:US
Mailing Address - Phone:323-726-3868
Mailing Address - Fax:323-726-3870
Practice Address - Street 1:3106 WEST BEVERLY BLVD
Practice Address - Street 2:
Practice Address - City:MONTEBELLO
Practice Address - State:CA
Practice Address - Zip Code:90640
Practice Address - Country:US
Practice Address - Phone:323-726-3868
Practice Address - Fax:323-726-3870
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2009-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA17689363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA95-4430908OtherTAX ID
CAPA17689Medicaid
CAQ56774Medicare UPIN
CA95-4430908OtherTAX ID