Provider Demographics
NPI:1760425730
Name:FROST, CHARLES (PA-C)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:FROST
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 1:3340 E GOLDSTONE WAY
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-1026
Mailing Address - Country:US
Mailing Address - Phone:208-302-7640
Mailing Address - Fax:208-302-7625
Practice Address - Street 1:4400 E FLAMINGO AVE
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83687-3402
Practice Address - Country:US
Practice Address - Phone:208-302-7640
Practice Address - Fax:208-302-7625
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2016-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA194363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID804051800Medicaid
ID1666255Medicare ID - Type Unspecified
ID804051800Medicaid