Provider Demographics
NPI:1497741995
Name:SELF, CHARLES EDWARD (PA-C)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:EDWARD
Last Name:SELF
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 1:1611 GERMANTOWN RD
Mailing Address - Street 2:
Mailing Address - City:MINDEN
Mailing Address - State:LA
Mailing Address - Zip Code:71055-1301
Mailing Address - Country:US
Mailing Address - Phone:318-469-6331
Mailing Address - Fax:318-377-2324
Practice Address - Street 1:1111 HOMER RD
Practice Address - Street 2:
Practice Address - City:MINDEN
Practice Address - State:LA
Practice Address - Zip Code:71055-3027
Practice Address - Country:US
Practice Address - Phone:318-377-7500
Practice Address - Fax:318-377-2324
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-21
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPA.A10425.RX363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAPA.A10425.RXOtherLA STATE PA LICENSE
LAP93043Medicare UPIN
LA5CF78P506Medicare ID - Type UnspecifiedMEDICARE PROVIDER NO.