Provider Demographics
NPI:1275053910
Name:WOOD, CHARLIE ELIZABETH (PA)
Entity Type:Individual
Prefix:
First Name:CHARLIE
Middle Name:ELIZABETH
Last Name:WOOD
Suffix:
Gender:F
Credentials:PA
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 146
Mailing Address - Street 2:
Mailing Address - City:JOINERVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75658-0146
Mailing Address - Country:US
Mailing Address - Phone:903-520-4301
Mailing Address - Fax:
Practice Address - Street 1:4293 KINSEY DR
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703-1004
Practice Address - Country:US
Practice Address - Phone:903-592-5670
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-23
Last Update Date:2023-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA11666363A00000X
TX363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant