Provider Demographics
NPI:1689661050
Name:AINGE, CHARLOTTE S (PAC)
Entity Type:Individual
Prefix:
First Name:CHARLOTTE
Middle Name:S
Last Name:AINGE
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:TUCK
Other - Middle Name:STELLA
Other - Last Name:AINGE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PAC
Mailing Address - Street 1:700 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MOSCOW
Mailing Address - State:ID
Mailing Address - Zip Code:83843-3046
Mailing Address - Country:US
Mailing Address - Phone:208-882-4511
Mailing Address - Fax:
Practice Address - Street 1:156 N. 6TH ST
Practice Address - Street 2:
Practice Address - City:POTLATCH
Practice Address - State:ID
Practice Address - Zip Code:83855
Practice Address - Country:US
Practice Address - Phone:208-875-2380
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-30
Last Update Date:2019-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA449363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010149468OtherREGENCE BS OF ID
WA0195084OtherDEPT OF LABOR & INDUSTRY
WA8325052Medicaid
IDPAUS3OtherBLUE CROSS OF ID
ID806474000Medicaid
CS6290Medicare Oscar/Certification
0595810002Medicare NSC
P77462Medicare UPIN
ID000010149468OtherREGENCE BS OF ID
ID806474000Medicaid
WA0195084OtherDEPT OF LABOR & INDUSTRY
P00382133Medicare PIN