Provider Demographics
NPI:1962422956
Name:DAVIS, CHARLES J (PA-C)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:J
Last Name:DAVIS
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 1:3600 LIND AVE SW
Mailing Address - Street 2:SUITE 100 ATTN CREDENTIALING
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98057-4970
Mailing Address - Country:US
Mailing Address - Phone:425-690-2715
Mailing Address - Fax:
Practice Address - Street 1:14410 SE PETROVITSKY RD STE 104
Practice Address - Street 2:
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98058-8900
Practice Address - Country:US
Practice Address - Phone:425-690-3405
Practice Address - Fax:425-690-9405
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2020-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10004461363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8971468OtherMEDICARE W VALLEY MEDICAL GROUP - RENTON
WA1023188Medicaid