Provider Demographics
NPI:1760472880
Name:SMERGLIA, CHARLES LOUIS (PA-C)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:LOUIS
Last Name:SMERGLIA
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:PO BOX 218
Mailing Address - Street 2:401 BURRO ALLEY
Mailing Address - City:MORENCI
Mailing Address - State:AZ
Mailing Address - Zip Code:85540-0218
Mailing Address - Country:US
Mailing Address - Phone:928-865-9184
Mailing Address - Fax:928-865-9186
Practice Address - Street 1:401 BURRO ALY
Practice Address - Street 2:
Practice Address - City:MORENCI
Practice Address - State:AZ
Practice Address - Zip Code:85540-9647
Practice Address - Country:US
Practice Address - Phone:928-865-9184
Practice Address - Fax:928-865-9186
Is Sole Proprietor?:No
Enumeration Date:2005-10-28
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3000363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZR81016Medicare UPIN