Provider Demographics
NPI:1033301718
Name:SHORT, CHARLES D JR (NP)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:D
Last Name:SHORT
Suffix:JR
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5000 HOPYARD RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:PLEASANTON
Mailing Address - State:CA
Mailing Address - Zip Code:94588-3348
Mailing Address - Country:US
Mailing Address - Phone:925-924-1600
Mailing Address - Fax:
Practice Address - Street 1:5000 HOPYARD RD
Practice Address - Street 2:SUITE 100
Practice Address - City:PLEASANTON
Practice Address - State:CA
Practice Address - Zip Code:94588-3348
Practice Address - Country:US
Practice Address - Phone:925-924-1600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-15
Last Update Date:2007-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX647464363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX647464OtherLICENSE