Provider Demographics
NPI:1639151020
Name:FLETCHER, CHARLES HENRY (PA-C)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:HENRY
Last Name:FLETCHER
Suffix:
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 1:2600 N WOODLAWN BLVD
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67220-2729
Mailing Address - Country:US
Mailing Address - Phone:316-684-3838
Mailing Address - Fax:316-858-2530
Practice Address - Street 1:2600 N WOODLAWN BLVD
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67220-2729
Practice Address - Country:US
Practice Address - Phone:316-684-3838
Practice Address - Fax:316-858-2521
Is Sole Proprietor?:No
Enumeration Date:2005-11-19
Last Update Date:2014-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS15-00518363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100340590HMedicaid
KS100340590HMedicaid