Healthcare Provider Details

I. General information

NPI: 1275739435
Provider Name (Legal Business Name): KEVIN KURT CHARLES PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/25/2007
Last Update Date: 11/20/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

576 JEFFERSON AVE
FORT EUSTIS VA
23604-1602
US

IV. Provider business mailing address

576 JEFFERSON AVE
FORT EUSTIS VA
23604-1602
US

V. Phone/Fax

Practice location:
  • Phone: 757-314-7500
  • Fax:
Mailing address:
  • Phone: 757-314-7500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110002248
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: