Provider Demographics
NPI:1275739435
Name:CHARLES, KEVIN KURT (PA-C)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:KURT
Last Name:CHARLES
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 1:576 JEFFERSON AVE
Mailing Address - Street 2:
Mailing Address - City:FORT EUSTIS
Mailing Address - State:VA
Mailing Address - Zip Code:23604-1602
Mailing Address - Country:US
Mailing Address - Phone:757-314-7500
Mailing Address - Fax:
Practice Address - Street 1:576 JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:FORT EUSTIS
Practice Address - State:VA
Practice Address - Zip Code:23604-1602
Practice Address - Country:US
Practice Address - Phone:757-314-7500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-25
Last Update Date:2014-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110002248363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAVV5086AMedicare PIN