Provider Demographics
NPI:1649490814
Name:LITTELL, CHARLES DOUGLAS (PA-C)
Entity type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:DOUGLAS
Last Name:LITTELL
Suffix:
Gender:M
Credentials:PA-C
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 872
Mailing Address - Street 2:
Mailing Address - City:ROBERTSON
Mailing Address - State:WY
Mailing Address - Zip Code:82944-0173
Mailing Address - Country:US
Mailing Address - Phone:208-227-3536
Mailing Address - Fax:
Practice Address - Street 1:26 MILES WEST OF GREEN RIVER
Practice Address - Street 2:
Practice Address - City:GREEN RIVER
Practice Address - State:WY
Practice Address - Zip Code:82935-0872
Practice Address - Country:US
Practice Address - Phone:307-872-2250
Practice Address - Fax:307-872-2569
Is Sole Proprietor?:No
Enumeration Date:2007-04-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY218363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WYS30283Medicare UPIN