Provider Demographics
NPI:1922054808
Name:MILITELLO, CHARLES (PA-C)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:MILITELLO
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 1:261 N ROOSEVELT AVE
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85226-2616
Mailing Address - Country:US
Mailing Address - Phone:480-677-8282
Mailing Address - Fax:
Practice Address - Street 1:261 N ROOSEVELT AVE
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85226-2616
Practice Address - Country:US
Practice Address - Phone:480-677-8282
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2022-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE752363AM0700X
GA5507363AM0700X
AZ8487363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003149992BMedicaid
AZ095004Medicaid
GA003149992AMedicaid
NE269736Medicare PIN
GA003149992BMedicaid
R95858Medicare UPIN
GA003149992AMedicaid