Healthcare Provider Details

I. General information

NPI: 1316062573
Provider Name (Legal Business Name): CHARLES WALBOURN PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3200 AVENUE E
HONDO TX
78861
US

IV. Provider business mailing address

3200 AVENUE E
HONDO TX
78861
US

V. Phone/Fax

Practice location:
  • Phone: 830-426-7444
  • Fax: 830-426-7468
Mailing address:
  • Phone: 830-426-7444
  • Fax: 830-426-7468

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA00820
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: