Provider Demographics
NPI:1083139133
Name:CHARBONNEAU, JOSHUA ADAM
Entity Type:Individual
Prefix:MR
First Name:JOSHUA
Middle Name:ADAM
Last Name:CHARBONNEAU
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7020 WYTHEVILLE CIR
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22407-3726
Mailing Address - Country:US
Mailing Address - Phone:302-430-4229
Mailing Address - Fax:804-237-0424
Practice Address - Street 1:7020 WYTHEVILLE CIR
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22407-3726
Practice Address - Country:US
Practice Address - Phone:302-430-4229
Practice Address - Fax:804-237-0424
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-10
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAA67161062172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver