Provider Demographics
NPI:1134149859
Name:CHARITY, JOHN CHARLES (NP-BC)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:CHARLES
Last Name:CHARITY
Suffix:
Gender:M
Credentials:NP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:503 BROADMOOR BLVD
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71105-2023
Mailing Address - Country:US
Mailing Address - Phone:318-868-7537
Mailing Address - Fax:318-868-7537
Practice Address - Street 1:503 BROADMOOR BLVD
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-2023
Practice Address - Country:US
Practice Address - Phone:318-868-7537
Practice Address - Fax:318-868-7537
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2013-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARN071365363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1545201Medicaid
LAS65751Medicare UPIN
LA4H760F600Medicare ID - Type Unspecified