Provider Demographics
NPI:1396855805
Name:HURST, CHARLES ALLEN III (PT)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:ALLEN
Last Name:HURST
Suffix:III
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4107 HOHE ST
Mailing Address - Street 2:
Mailing Address - City:HOMER
Mailing Address - State:AK
Mailing Address - Zip Code:99603-7008
Mailing Address - Country:US
Mailing Address - Phone:907-235-0687
Mailing Address - Fax:907-235-4017
Practice Address - Street 1:4107 HOHE ST
Practice Address - Street 2:
Practice Address - City:HOMER
Practice Address - State:AK
Practice Address - Zip Code:99603-7008
Practice Address - Country:US
Practice Address - Phone:907-235-0687
Practice Address - Fax:907-235-4017
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2018-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKPT2323225100000X
CA278082251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYVAD000Medicare UPIN