Provider Demographics
NPI:1700564846
Name:CHARLES, NESLY ISMENARD (PA)
Entity Type:Individual
Prefix:MR
First Name:NESLY
Middle Name:ISMENARD
Last Name:CHARLES
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 1:2926 E OSBORN RD APT 321
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-7080
Mailing Address - Country:US
Mailing Address - Phone:561-574-5787
Mailing Address - Fax:
Practice Address - Street 1:5406 W GLENN DR STE 3
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85301-2662
Practice Address - Country:US
Practice Address - Phone:623-270-6336
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-10
Last Update Date:2024-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI21-268246ZC0007X
AZ10014363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical AssistantGroup - Multi-Specialty