Healthcare Provider Details

I. General information

NPI: 1659814663
Provider Name (Legal Business Name): CHARLES GAST
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: CHARLIE GAST MD

II. Dates (important events)

Enumeration Date: 11/22/2016
Last Update Date: 08/04/2023
Certification Date: 08/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 E ELIZABETH ST STE F101
FORT COLLINS CO
80524-4044
US

IV. Provider business mailing address

15730 SW MISTY CT
BEAVERTON OR
97007-4924
US

V. Phone/Fax

Practice location:
  • Phone: 970-221-1177
  • Fax:
Mailing address:
  • Phone: 970-691-7924
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number0070200
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: