Provider Demographics
NPI:1013973791
Name:PIERCE, CHARLES CROWELL (PA)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:CROWELL
Last Name:PIERCE
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 846098
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-6098
Mailing Address - Country:US
Mailing Address - Phone:903-324-6450
Mailing Address - Fax:
Practice Address - Street 1:619 S FLEISHEL AVE STE 305
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-2004
Practice Address - Country:US
Practice Address - Phone:903-606-1173
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-22
Last Update Date:2023-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA05595363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX214077401Medicaid
TX752616977006OtherTRICARE
TX824N49OtherBCBS
TX752616977-103OtherTRICARE
TX75-2616977-095OtherTRICARE
TX752616977006OtherTRICARE
TX824N49OtherBCBS
TX752616977-103OtherTRICARE