Provider Demographics
NPI:1154641595
Name:PELTON, CHARLES L JR (PA-C)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:L
Last Name:PELTON
Suffix:JR
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1460
Mailing Address - Street 2:
Mailing Address - City:ABERDEEN
Mailing Address - State:SD
Mailing Address - Zip Code:57402-1460
Mailing Address - Country:US
Mailing Address - Phone:605-622-2856
Mailing Address - Fax:605-622-2859
Practice Address - Street 1:310 S PENN ST
Practice Address - Street 2:SUITE 202
Practice Address - City:ABERDEEN
Practice Address - State:SD
Practice Address - Zip Code:57401-4553
Practice Address - Country:US
Practice Address - Phone:605-622-2573
Practice Address - Fax:605-622-2574
Is Sole Proprietor?:No
Enumeration Date:2010-06-08
Last Update Date:2010-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0748363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant