Provider Demographics
NPI:1043220122
Name:WINFREY, CHARLES DAVID (PA)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:DAVID
Last Name:WINFREY
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1414 ELBA HWY
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:AL
Mailing Address - Zip Code:36079-6020
Mailing Address - Country:US
Mailing Address - Phone:334-670-6726
Mailing Address - Fax:334-670-6731
Practice Address - Street 1:193 OATES DR
Practice Address - Street 2:
Practice Address - City:NEWTON
Practice Address - State:AL
Practice Address - Zip Code:36352-4312
Practice Address - Country:US
Practice Address - Phone:334-299-3592
Practice Address - Fax:334-299-3870
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2013-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPA-59363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL631804042Medicaid
AL51532172OtherBCBS
S45737Medicare UPIN
AL631804042Medicaid