Provider Demographics
NPI:1922165026
Name:WHELAN, CHARLES D III (PA-C)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:D
Last Name:WHELAN
Suffix:III
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 1:1115 SE 164TH AVE
Mailing Address - Street 2:DEPT 358
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98683-9324
Mailing Address - Country:US
Mailing Address - Phone:360-733-2092
Mailing Address - Fax:360-733-4013
Practice Address - Street 1:3015 SQUALICUM PKWY
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98225-1945
Practice Address - Country:US
Practice Address - Phone:360-733-2092
Practice Address - Fax:360-733-4013
Is Sole Proprietor?:No
Enumeration Date:2007-01-02
Last Update Date:2014-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10005113363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1922165026Medicaid
WA0111WHOtherREGENCE
WA0266104OtherL&I AND CRIME VICTIMS
WAG8894013Medicare PIN