Provider Demographics
NPI:1881713345
Name:WETMORE, CHARLES F (APRN)
Entity type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:F
Last Name:WETMORE
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:13 PECK ST
Mailing Address - Street 2:
Mailing Address - City:NORTH HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06473-2308
Mailing Address - Country:US
Mailing Address - Phone:203-239-4627
Mailing Address - Fax:203-234-8533
Practice Address - Street 1:13 PECK ST
Practice Address - Street 2:
Practice Address - City:NORTH HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06473-2308
Practice Address - Country:US
Practice Address - Phone:203-239-4627
Practice Address - Fax:203-234-8533
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-28
Last Update Date:2014-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002351363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008017640Medicaid