Provider Demographics
NPI:1407880669
Name:BELLANGER, CHARLES (PA)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:BELLANGER
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6032 W WILLOW AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85304-1101
Mailing Address - Country:US
Mailing Address - Phone:623-979-4699
Mailing Address - Fax:623-878-4629
Practice Address - Street 1:1300 N 12TH ST STE 301
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85006-2813
Practice Address - Country:US
Practice Address - Phone:602-239-6968
Practice Address - Fax:602-239-4144
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2008-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1065363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA103391-06Medicaid
CA103391-06Medicaid
CAR55687Medicare UPIN