Provider Demographics
NPI:1558445411
Name:CHARLES, ELVIA L (PA)
Entity Type:Individual
Prefix:
First Name:ELVIA
Middle Name:L
Last Name:CHARLES
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4004 BEYER BLVD
Mailing Address - Street 2:
Mailing Address - City:SAN YSIDRO
Mailing Address - State:CA
Mailing Address - Zip Code:92173-2007
Mailing Address - Country:US
Mailing Address - Phone:619-428-4463
Mailing Address - Fax:619-428-2625
Practice Address - Street 1:4004 BEYER BLVD
Practice Address - Street 2:
Practice Address - City:SAN YSIDRO
Practice Address - State:CA
Practice Address - Zip Code:92173-2007
Practice Address - Country:US
Practice Address - Phone:619-428-4463
Practice Address - Fax:619-428-2625
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2007-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA17240363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FHC18880FOtherMEDICAL
Q40632Medicare UPIN
W5740Medicare ID - Type Unspecified