Provider Demographics
NPI:1235464918
Name:ALDRICH, CHARLES M (PA-C)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:M
Last Name:ALDRICH
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:MR
Other - First Name:CHASE
Other - Middle Name:M
Other - Last Name:ALDRICH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA-C
Mailing Address - Street 1:620 SKYLINE DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38301-3923
Mailing Address - Country:US
Mailing Address - Phone:731-541-6574
Mailing Address - Fax:731-541-6042
Practice Address - Street 1:620 SKYLINE DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38301-3923
Practice Address - Country:US
Practice Address - Phone:731-541-6574
Practice Address - Fax:731-541-6042
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-13
Last Update Date:2009-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPA 1784363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN12221983OtherBIRTH DATE