Provider Demographics
NPI:1508588484
Name:AU, CHARLIE C (CRNA)
Entity Type:Individual
Prefix:
First Name:CHARLIE
Middle Name:C
Last Name:AU
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19720 CAROLINE HARRISON ST
Mailing Address - Street 2:
Mailing Address - City:MANOR
Mailing Address - State:TX
Mailing Address - Zip Code:78653-2479
Mailing Address - Country:US
Mailing Address - Phone:512-296-8709
Mailing Address - Fax:
Practice Address - Street 1:736 IRVING AVE
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13210-1602
Practice Address - Country:US
Practice Address - Phone:315-470-7646
Practice Address - Fax:315-470-7649
Is Sole Proprietor?:No
Enumeration Date:2022-09-16
Last Update Date:2023-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX935201163W00000X
NY870259367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse