Provider Demographics
NPI:1346343274
Name:CHARLESWORTH, TODD J (PA C)
Entity Type:Individual
Prefix:
First Name:TODD
Middle Name:J
Last Name:CHARLESWORTH
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 1:1 BOONE RD
Mailing Address - Street 2:
Mailing Address - City:BREMERTON
Mailing Address - State:WA
Mailing Address - Zip Code:98312-1894
Mailing Address - Country:US
Mailing Address - Phone:425-304-4160
Mailing Address - Fax:
Practice Address - Street 1:2901 SQUALICUM PKWY
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98225-1851
Practice Address - Country:US
Practice Address - Phone:360-738-6765
Practice Address - Fax:360-738-6377
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-06
Last Update Date:2011-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10005145363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0218367OtherLIWA
WA5357CHOtherBSWA
WA8474355Medicaid
WAG8865148Medicare PIN
WVCH6032281Medicare PIN
WA8474355Medicaid