Provider Demographics
NPI:1053498519
Name:BEAN, CHARLES P (PA)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:P
Last Name:BEAN
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:818 SAINT SEBASTIAN WAY STE 403
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30901-2654
Mailing Address - Country:US
Mailing Address - Phone:706-722-0705
Mailing Address - Fax:762-333-0496
Practice Address - Street 1:818 SAINT SEBASTIAN WAY STE 403
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30901-2654
Practice Address - Country:US
Practice Address - Phone:706-722-0705
Practice Address - Fax:762-333-0496
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2015-03-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
SCA768363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCP24361Medicare UPIN
SCP243611941Medicare ID - Type Unspecified
20297I0639Medicare PIN