Healthcare Provider Details

I. General information

NPI: 1760472880
Provider Name (Legal Business Name): CHARLES LOUIS SMERGLIA PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/28/2005
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 BURRO ALY
MORENCI AZ
85540-9647
US

IV. Provider business mailing address

PO BOX 218 401 BURRO ALLEY
MORENCI AZ
85540-0218
US

V. Phone/Fax

Practice location:
  • Phone: 928-865-9184
  • Fax: 928-865-9186
Mailing address:
  • Phone: 928-865-9184
  • Fax: 928-865-9186

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number3000
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: