Healthcare Provider Details

I. General information

NPI: 1629529540
Provider Name (Legal Business Name): CHARLES WILLIAM-WESLEY HURD PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/14/2016
Last Update Date: 07/24/2024
Certification Date: 07/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

127 S SAN VICENTE BLVD STE A3600
LOS ANGELES CA
90048-3311
US

IV. Provider business mailing address

2625 E DIVISADERO ST
FRESNO CA
93721-1431
US

V. Phone/Fax

Practice location:
  • Phone: 310-423-1153
  • Fax: 310-423-6795
Mailing address:
  • Phone: 559-453-5200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number53933
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: