Provider Demographics
NPI:1942502992
Name:PHOENIX, CHARLA MARIE (PAC)
Entity Type:Individual
Prefix:MS
First Name:CHARLA
Middle Name:MARIE
Last Name:PHOENIX
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:620 STANTON CHRISTIANA RD
Mailing Address - Street 2:SUITE 302
Mailing Address - City:NEWARK
Mailing Address - State:DE
Mailing Address - Zip Code:19713-2133
Mailing Address - Country:US
Mailing Address - Phone:302-892-9400
Mailing Address - Fax:
Practice Address - Street 1:620 STANTON CHRISTIANA RD
Practice Address - Street 2:SUITE 302
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19713-2133
Practice Address - Country:US
Practice Address - Phone:302-892-9400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-24
Last Update Date:2010-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC5-0000735363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical