Provider Demographics
NPI:1265411581
Name:HITCHCOCK, CHARLES SCOT (PA)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:SCOT
Last Name:HITCHCOCK
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 1:9040 A JACKSON AVENUE, JOINT BASE LEWIS-MCCHORD 98341
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98341
Mailing Address - Country:US
Mailing Address - Phone:253-477-0822
Mailing Address - Fax:
Practice Address - Street 1:9040A JACKSON AVENUE, JOINT BASE LEWIS-MCCHORD 98341
Practice Address - Street 2:
Practice Address - City:JOINT BASE LEWIS-MCCHORD
Practice Address - State:WA
Practice Address - Zip Code:98341
Practice Address - Country:US
Practice Address - Phone:253-477-0822
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-13
Last Update Date:2019-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1070438363AM0700X
363AM0700X
SCPA2706363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
000OTHMedicare UPIN