Healthcare Provider Details

I. General information

NPI: 1356072607
Provider Name (Legal Business Name): MACHEL CHARLES PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2022
Last Update Date: 11/15/2023
Certification Date: 11/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

593 EDDY ST
PROVIDENCE RI
02903-4923
US

IV. Provider business mailing address

117 ELLENFIELD ST STE 101
PROVIDENCE RI
02905-4541
US

V. Phone/Fax

Practice location:
  • Phone: 401-444-7585
  • Fax: 401-444-1766
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA01461
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: