Provider Demographics
NPI:1548231525
Name:MENGER, CHARLES MATTHEW (PA)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:MATTHEW
Last Name:MENGER
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 1:4728 E LANCASTER AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76103-3836
Mailing Address - Country:US
Mailing Address - Phone:817-413-0943
Mailing Address - Fax:817-413-6481
Practice Address - Street 1:4728 E. LANCASTER AVE.
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76103-3638
Practice Address - Country:US
Practice Address - Phone:817-413-0943
Practice Address - Fax:817-413-6481
Is Sole Proprietor?:No
Enumeration Date:2006-01-30
Last Update Date:2008-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA00031363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX193740101Medicaid
TX8N8358OtherBLUE CROSS BLUE SHIELD
TXP00342395OtherRAILROAD MEDICARE
TXP00342395OtherRAILROAD MEDICARE