Provider Demographics
NPI:1588823157
Name:GENTZSCH, CHARLES EDWARD (RN, MN, MA, EDD, FNP)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:EDWARD
Last Name:GENTZSCH
Suffix:
Gender:M
Credentials:RN, MN, MA, EDD, FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1913 BLACKHAWK AVE
Mailing Address - Street 2:
Mailing Address - City:OCEANSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92056-2907
Mailing Address - Country:US
Mailing Address - Phone:760-724-2942
Mailing Address - Fax:
Practice Address - Street 1:1000 VALE TERRACE DR
Practice Address - Street 2:
Practice Address - City:VISTA
Practice Address - State:CA
Practice Address - Zip Code:92084-5218
Practice Address - Country:US
Practice Address - Phone:760-631-5000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-08
Last Update Date:2011-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANPF11330363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACU608Medicare PIN