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NPI Code Detail

MEDICARE: MR. CHARLES W ANDEREGG PAC

MEDICARE: MR. CHARLES W ANDEREGG PAC
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1363AS0400XSurgical Physician AssistantMA052594PA
2363AS0400XSurgical Physician AssistantPA10003420WA

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1124056437
Entity Type Code : Individual
Provider Name (Legal Business Name) : MR. CHARLES W ANDEREGG PAC
Provider Business Mailing Address
First Line : PO BOX 1668
Second Line :
City : SHELTON
State : WA
Zip : 98584-5001
Country : US
Telephone Number : 360-427-9549
Fax Number : 360-427-3661
Provider Business Practice Location Address
First Line : 1701 N 13TH ST STE A
Second Line :
City : SHELTON
State : WA
Zip : 98584-2077
Country : US
Telephone Number : 360-426-2653
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/28/2006
Last Update Date : 11/16/2020

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