MEDICARE: CHARLES B. WORLEY PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AM0700X	Medical Physician Assistant	PA17689	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	95-4430908	OTHER	CA	TAX ID
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1699702662
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHARLES B. WORLEY PA-C

Provider Business Mailing Address
First Line	:	3725 MIDVALE AVE #4
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90034
Country	:	US
Telephone Number	:	323-726-3868
Fax Number	:	323-726-3870

Provider Business Practice Location Address
First Line	:	3106 WEST BEVERLY BLVD
Second Line	:
City	:	MONTEBELLO
State	:	CA
Zip	:	90640
Country	:	US
Telephone Number	:	323-726-3868
Fax Number	:	323-726-3870

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/27/2006
Last Update Date	:	12/08/2009

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