Provider Demographics
NPI:1922284504
Name:CHARLES, CANDACE DONYUSHA (PA)
Entity Type:Individual
Prefix:
First Name:CANDACE
Middle Name:DONYUSHA
Last Name:CHARLES
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:CANDACE
Other - Middle Name:DONYUSHA
Other - Last Name:MOSES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3 PROFESSIONAL DR
Mailing Address - Street 2:STE B
Mailing Address - City:ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62002-5067
Mailing Address - Country:US
Mailing Address - Phone:618-465-7177
Mailing Address - Fax:618-465-7176
Practice Address - Street 1:4965 STONE FALLS CTR STE 7
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:IL
Practice Address - Zip Code:62269-7803
Practice Address - Country:US
Practice Address - Phone:618-726-2500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-14
Last Update Date:2018-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085004583363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILF400206491Medicare PIN