Provider Demographics
NPI:1275225492
Name:CHARGUALAF, MARK LEWIS (PA-C)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:LEWIS
Last Name:CHARGUALAF
Suffix:
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 1:1400 MIDTOWN AVE APT 406
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29464-3875
Mailing Address - Country:US
Mailing Address - Phone:865-748-8987
Mailing Address - Fax:
Practice Address - Street 1:1327 ASHLEY RIVER RD
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29407-5384
Practice Address - Country:US
Practice Address - Phone:843-405-9474
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-25
Last Update Date:2023-05-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
SC4632363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant