Provider Demographics
NPI:1801167473
Name:CHARLTON, MATTHEW DAVID (PA)
Entity type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:DAVID
Last Name:CHARLTON
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:500 W. FORT ST
Mailing Address - Street 2:# 111
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702
Mailing Address - Country:US
Mailing Address - Phone:208-422-1000
Mailing Address - Fax:208-422-1319
Practice Address - Street 1:3377 RIVERBEND DR
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OR
Practice Address - Zip Code:97477-8803
Practice Address - Country:US
Practice Address - Phone:541-222-2402
Practice Address - Fax:541-222-2350
Is Sole Proprietor?:No
Enumeration Date:2012-01-13
Last Update Date:2022-02-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IDPA-959363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500682098Medicaid
ORR179379Medicare PIN