Provider Demographics
NPI:1619946498
Name:HANEY, CHARLES H III (PA-C)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:H
Last Name:HANEY
Suffix:III
Gender:M
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 1:1201 GRAMPIAN BLVD
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSPORT
Mailing Address - State:PA
Mailing Address - Zip Code:17701-1900
Mailing Address - Country:US
Mailing Address - Phone:570-326-8723
Mailing Address - Fax:570-326-8922
Practice Address - Street 1:740 HIGH ST STE 2001
Practice Address - Street 2:
Practice Address - City:WILLIAMSPORT
Practice Address - State:PA
Practice Address - Zip Code:17701-3102
Practice Address - Country:US
Practice Address - Phone:570-321-3165
Practice Address - Fax:570-321-3166
Is Sole Proprietor?:No
Enumeration Date:2006-03-15
Last Update Date:2020-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA001405L363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
R08499Medicare UPIN
PA675425Medicare ID - Type Unspecified