Healthcare Provider Details

I. General information

NPI: 1194702712
Provider Name (Legal Business Name): CHARLES CADDY II RPA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/23/2005
Last Update Date: 12/07/2020
Certification Date: 12/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

485 N KS HWY 2
ANTHONY KS
67003-2526
US

IV. Provider business mailing address

485 N KS HWY 2
ANTHONY KS
67003-2526
US

V. Phone/Fax

Practice location:
  • Phone: 620-914-1200
  • Fax: 620-914-1256
Mailing address:
  • Phone: 620-914-1200
  • Fax: 620-914-1256

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1500771
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: