Provider Demographics
NPI:1912473240
Name:CHARLESTON, KIRBY MICHAEL (PTA)
Entity Type:Individual
Prefix:MR
First Name:KIRBY
Middle Name:MICHAEL
Last Name:CHARLESTON
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1950 BRIAN LN
Mailing Address - Street 2:
Mailing Address - City:YORK
Mailing Address - State:PA
Mailing Address - Zip Code:17404-1315
Mailing Address - Country:US
Mailing Address - Phone:717-767-9328
Mailing Address - Fax:
Practice Address - Street 1:1700 NORMANDIE DR
Practice Address - Street 2:
Practice Address - City:YORK
Practice Address - State:PA
Practice Address - Zip Code:17408-9748
Practice Address - Country:US
Practice Address - Phone:717-764-6262
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-14
Last Update Date:2018-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PATE1000191208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation