Provider Demographics
NPI:1104845049
Name:WOOD, CHARLES C (PA)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:C
Last Name:WOOD
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2636 LOUDOUN ST
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23456-2438
Mailing Address - Country:US
Mailing Address - Phone:757-301-9978
Mailing Address - Fax:757-301-9978
Practice Address - Street 1:2636 LOUDOUN ST
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23456-2438
Practice Address - Country:US
Practice Address - Phone:757-301-9978
Practice Address - Fax:757-301-9978
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110001510363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA278240OtherANTHEM
P00013235OtherRAILROAD MEDICARE
MW0899495OtherDEA CERTIFICATE
P65166Medicare UPIN
MW0899495OtherDEA CERTIFICATE