Provider Demographics
NPI:1770629784
Name:REPPE, CHARLES ROYAL (PA13860)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:ROYAL
Last Name:REPPE
Suffix:
Gender:M
Credentials:PA13860
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2410 RUSSELL ST
Mailing Address - Street 2:APT. #C
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94705-2077
Mailing Address - Country:US
Mailing Address - Phone:510-843-1235
Mailing Address - Fax:
Practice Address - Street 1:27200 CALAROGA AVE
Practice Address - Street 2:ST. ROSE HOSPITAL
Practice Address - City:HAYWARD
Practice Address - State:CA
Practice Address - Zip Code:94545-4339
Practice Address - Country:US
Practice Address - Phone:510-264-4000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA13860282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA13860OtherPHYSICIAN ASSISTANT