Provider Demographics
NPI:1700105194
Name:KLEIN, CHARLES W III (PA-C)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:W
Last Name:KLEIN
Suffix:III
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 1:218 QUARTERMAN ST
Mailing Address - Street 2:
Mailing Address - City:WAYCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:31501-3547
Mailing Address - Country:US
Mailing Address - Phone:912-287-0301
Mailing Address - Fax:912-287-1568
Practice Address - Street 1:218 QUARTERMAN ST
Practice Address - Street 2:
Practice Address - City:WAYCROSS
Practice Address - State:GA
Practice Address - Zip Code:31501-3547
Practice Address - Country:US
Practice Address - Phone:912-287-0301
Practice Address - Fax:912-287-0301
Is Sole Proprietor?:No
Enumeration Date:2010-05-25
Last Update Date:2014-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA005819363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003103924DMedicaid