Healthcare Provider Details

I. General information

NPI: 1497741995
Provider Name (Legal Business Name): CHARLES EDWARD SELF PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 09/21/2005
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 HOMER RD
MINDEN LA
71055-3027
US

IV. Provider business mailing address

1611 GERMANTOWN RD
MINDEN LA
71055-1301
US

V. Phone/Fax

Practice location:
  • Phone: 318-377-7500
  • Fax: 318-377-2324
Mailing address:
  • Phone: 318-469-6331
  • Fax: 318-377-2324

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA.A10425.RX
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: