Provider Demographics
NPI:1598122947
Name:STAPLES, CHARLES JR
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:STAPLES
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 SYLVAN LAKE RD
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06779-1450
Mailing Address - Country:US
Mailing Address - Phone:203-260-8744
Mailing Address - Fax:
Practice Address - Street 1:205 SYLVAN LAKE RD
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:CT
Practice Address - Zip Code:06779-1450
Practice Address - Country:US
Practice Address - Phone:203-260-8744
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-15
Last Update Date:2016-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTF1015603363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily