=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447616040
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHARLES JOSHUA GESKE P.A.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/12/2016
-----------------------------------------------------
Last Update Date | 04/18/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7001 ROGERS AVE STE 401A
-----------------------------------------------------
City | FORT SMITH
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72903-4034
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-314-4650
-----------------------------------------------------
Fax | 479-452-9459
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 776084
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60677-6084
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-364-4200
-----------------------------------------------------
Fax | 314-364-6321
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | PA-650
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------