Provider Demographics
NPI:1235695990
Name:REWIS, CHARLES JORDY (NP-C)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:JORDY
Last Name:REWIS
Suffix:
Gender:M
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1921 ALICE ST STE 4B
Mailing Address - Street 2:
Mailing Address - City:WAYCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:31501-6257
Mailing Address - Country:US
Mailing Address - Phone:912-385-5690
Mailing Address - Fax:912-285-1753
Practice Address - Street 1:228 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:JESUP
Practice Address - State:GA
Practice Address - Zip Code:31545-0102
Practice Address - Country:US
Practice Address - Phone:912-352-1700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-18
Last Update Date:2021-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN248151363LA2200X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health