Provider Demographics
NPI:1881874394
Name:HUMPHREY, CHARLES BRADY (PA)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:BRADY
Last Name:HUMPHREY
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:919 HIDDEN RDG
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75038-3813
Mailing Address - Country:US
Mailing Address - Phone:469-282-2711
Mailing Address - Fax:469-282-2609
Practice Address - Street 1:2604 SAINT MICHAEL DR
Practice Address - Street 2:STE 425
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75503-2379
Practice Address - Country:US
Practice Address - Phone:903-614-5600
Practice Address - Fax:903-614-5630
Is Sole Proprietor?:No
Enumeration Date:2007-11-13
Last Update Date:2021-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA02592363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200515720AMedicaid
TX297050101Medicaid
OK200515720AMedicaid
TXTXB152249Medicare PIN