Provider Demographics
NPI:1407997646
Name:HALL, CHARLES WILLIAM SR (PA)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:WILLIAM
Last Name:HALL
Suffix:SR
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 786
Mailing Address - Street 2:
Mailing Address - City:CHINA
Mailing Address - State:TX
Mailing Address - Zip Code:77613-0786
Mailing Address - Country:US
Mailing Address - Phone:409-752-2301
Mailing Address - Fax:409-752-5054
Practice Address - Street 1:415 N BROADWAY
Practice Address - Street 2:
Practice Address - City:CHINA
Practice Address - State:TX
Practice Address - Zip Code:77613
Practice Address - Country:US
Practice Address - Phone:409-752-2301
Practice Address - Fax:409-752-5054
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-09
Last Update Date:2012-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA01495363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX141597803Medicaid
TXPA01495OtherLICENSE NUMBER
TXPA01495OtherLICENSE NUMBER
TX141597803Medicaid