Provider Demographics
NPI:1659814663
Name:GAST, CHARLES
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:GAST
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:CHARLIE
Other - Middle Name:
Other - Last Name:GAST
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:15730 SW MISTY CT
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97007-4924
Mailing Address - Country:US
Mailing Address - Phone:970-691-7924
Mailing Address - Fax:
Practice Address - Street 1:1120 E ELIZABETH ST STE F101
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80524-4044
Practice Address - Country:US
Practice Address - Phone:970-221-1177
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-22
Last Update Date:2023-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0070200207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology