Provider Demographics
NPI:1376027557
Name:BALCOME, CHARLES DOUGLAS (ACNP)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:DOUGLAS
Last Name:BALCOME
Suffix:
Gender:M
Credentials:ACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22331 N 79TH DR
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85383-2157
Mailing Address - Country:US
Mailing Address - Phone:602-335-9374
Mailing Address - Fax:
Practice Address - Street 1:16601 N 40TH ST STE 204
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85032-3356
Practice Address - Country:US
Practice Address - Phone:602-633-3721
Practice Address - Fax:602-595-1127
Is Sole Proprietor?:No
Enumeration Date:2018-09-24
Last Update Date:2021-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP11604363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ443489Medicaid