Provider Demographics
NPI:1598996100
Name:CHARLES, EMMANUELLE C (PA-C)
Entity Type:Individual
Prefix:
First Name:EMMANUELLE
Middle Name:C
Last Name:CHARLES
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3945 LAWRENCEVILLE HWY NW
Mailing Address - Street 2:
Mailing Address - City:LILBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30047-2817
Mailing Address - Country:US
Mailing Address - Phone:770-910-2377
Mailing Address - Fax:770-910-2377
Practice Address - Street 1:715 QUEEN CITY PKWY
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-4348
Practice Address - Country:US
Practice Address - Phone:770-531-5115
Practice Address - Fax:770-531-5116
Is Sole Proprietor?:No
Enumeration Date:2009-07-30
Last Update Date:2014-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA005291363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003116541BMedicaid
GA003116541GMedicaid
GA003116541EMedicaid
GA003116541DMedicaid
GA003116541CMedicaid
GA003116541DMedicaid