Provider Demographics
NPI:1316903719
Name:WADSWORTH, CHARLES E (PA)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:E
Last Name:WADSWORTH
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:9101 STONY POINT DR
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23235
Mailing Address - Country:US
Mailing Address - Phone:804-330-9105
Mailing Address - Fax:804-287-6119
Practice Address - Street 1:9101 STONY POINT DR
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23235
Practice Address - Country:US
Practice Address - Phone:804-330-9105
Practice Address - Fax:804-287-6119
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110 840588363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA541203530OtherTAX IDENTIFICATION NUMBER
VA010187974Medicaid
970000503Medicare PIN
VA010187974Medicaid