1922165026 NPI number — CHARLES D WHELAN III PA-C

Table of content: CHARLES D WHELAN III PA-C (NPI 1922165026)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922165026 NPI number — CHARLES D WHELAN III PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WHELAN
Provider First Name:
CHARLES
Provider Middle Name:
D
Provider Name Prefix Text:
Provider Name Suffix Text:
III
Provider Credential Text:
PA-C
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1922165026
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/18/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1115 SE 164TH AVE
Provider Second Line Business Mailing Address:
DEPT 358
Provider Business Mailing Address City Name:
VANCOUVER
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98683-9324
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-733-2092
Provider Business Mailing Address Fax Number:
360-733-4013

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3015 SQUALICUM PKWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BELLINGHAM
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98225-1945
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-733-2092
Provider Business Practice Location Address Fax Number:
360-733-4013
Provider Enumeration Date:
01/02/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  PA10005113 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1922165026 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0111WH . This is a "REGENCE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 0266104 . This is a "L&I AND CRIME VICTIMS" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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