Provider Demographics
NPI:1932253242
Name:MAYFIELD, CHARLES W JR (PA-C)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:W
Last Name:MAYFIELD
Suffix:JR
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1225 E LATHAM AVE STE B
Mailing Address - Street 2:
Mailing Address - City:HEMET
Mailing Address - State:CA
Mailing Address - Zip Code:92543-4423
Mailing Address - Country:US
Mailing Address - Phone:951-929-2800
Mailing Address - Fax:951-929-2303
Practice Address - Street 1:1225 E LATHAM AVE STE B
Practice Address - Street 2:
Practice Address - City:HEMET
Practice Address - State:CA
Practice Address - Zip Code:92543-4423
Practice Address - Country:US
Practice Address - Phone:951-929-2800
Practice Address - Fax:951-929-2303
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNPA16292363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACA137652Medicaid
CACA137652Medicaid
MN970002849Medicare PIN
MN970002849Medicare PIN