Provider Demographics
NPI:1770858656
Name:PERRY, CHARLES AUSTIN II (APRN)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:AUSTIN
Last Name:PERRY
Suffix:II
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 776351
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6351
Mailing Address - Country:US
Mailing Address - Phone:502-588-9490
Mailing Address - Fax:502-272-5116
Practice Address - Street 1:210 E GRAY ST
Practice Address - Street 2:SUITE 1105
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-3900
Practice Address - Country:US
Practice Address - Phone:502-583-1697
Practice Address - Fax:502-583-2120
Is Sole Proprietor?:No
Enumeration Date:2012-03-12
Last Update Date:2021-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3007332363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000764051OtherANTHEM - NNIKY
KY134996OtherSIHO - NNIKY
IN201067550Medicaid
KY50038650OtherPASSPORT - NNIKY
KY7100201270Medicaid
KY000000764051OtherANTHEM - NNIKY