Provider Demographics
NPI:1821113119
Name:BARRET, CHARLES TIFFANY (PA-C)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:TIFFANY
Last Name:BARRET
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 1:3040 LILLY RD NE
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98506-3007
Mailing Address - Country:US
Mailing Address - Phone:360-491-7917
Mailing Address - Fax:
Practice Address - Street 1:90 SE KLAH CHE MIN DR
Practice Address - Street 2:
Practice Address - City:SHELTON
Practice Address - State:WA
Practice Address - Zip Code:98584-9216
Practice Address - Country:US
Practice Address - Phone:360-427-9006
Practice Address - Fax:360-427-1951
Is Sole Proprietor?:No
Enumeration Date:2007-03-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10000621363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8601197Medicaid
WA8601197Medicaid
WAAB07776Medicare ID - Type Unspecified