Provider Demographics
NPI:1588611313
Name:NAM, CHARLES (MD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:NAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1701 3RD ST SE
Mailing Address - Street 2:300
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98372-4511
Mailing Address - Country:US
Mailing Address - Phone:253-697-5767
Mailing Address - Fax:
Practice Address - Street 1:1701 3RD ST SE
Practice Address - Street 2:300
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98372-4511
Practice Address - Country:US
Practice Address - Phone:253-697-5767
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-27
Last Update Date:2011-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00032978207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA98371B002OtherTRICARE PROVIDER NUMBER
WANA7328OtherREGENCE RIDER NUMBER
WA0116426OtherL & I PROVIDER NUMBER
WA8178923Medicaid
WA5495135OtherAETNA PROVIDER NUMBER
WA91120349412OtherKPS PROVIDER NUMBER
WA0116426OtherL & I PROVIDER NUMBER