Healthcare Provider Details

I. General information

NPI: 1942502992
Provider Name (Legal Business Name): CHARLA MARIE PHOENIX PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/24/2010
Last Update Date: 01/13/2025
Certification Date: 01/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 HYGEIA DR STE 1420
NEWARK DE
19713-2049
US

IV. Provider business mailing address

620 STANTON CHRISTIANA RD SUITE 302
NEWARK DE
19713-2133
US

V. Phone/Fax

Practice location:
  • Phone: 302-623-3017
  • Fax: 302-266-9962
Mailing address:
  • Phone: 302-892-9400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberC0009749
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberC5-0000735
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: