Provider Demographics
NPI:1255981940
Name:STREET, CHARLES MATTHEW (PA)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:MATTHEW
Last Name:STREET
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:170 W TENNESSEE AVE
Mailing Address - Street 2:
Mailing Address - City:OAK RIDGE
Mailing Address - State:TN
Mailing Address - Zip Code:37830-6509
Mailing Address - Country:US
Mailing Address - Phone:865-482-1788
Mailing Address - Fax:865-482-1789
Practice Address - Street 1:170 W TENNESSEE AVE
Practice Address - Street 2:
Practice Address - City:OAK RIDGE
Practice Address - State:TN
Practice Address - Zip Code:37830-6509
Practice Address - Country:US
Practice Address - Phone:865-482-1788
Practice Address - Fax:865-482-1789
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-16
Last Update Date:2019-09-16
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical