Provider Demographics
NPI:1275247124
Name:WHITE, CHARLES WESLEY
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:WESLEY
Last Name:WHITE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 DEERFIELD LN
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:25840-6799
Mailing Address - Country:US
Mailing Address - Phone:304-890-1167
Mailing Address - Fax:
Practice Address - Street 1:113 DEERFIELD LN
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:WV
Practice Address - Zip Code:25840-6799
Practice Address - Country:US
Practice Address - Phone:304-890-1167
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-05
Last Update Date:2023-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant