Provider Demographics
NPI:1922054808
Name:MILITELLO, CHARLES (PA-C)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:MILITELLO
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3638 E SOUTHERN AVE STE C108
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85206-2564
Mailing Address - Country:US
Mailing Address - Phone:480-834-0771
Mailing Address - Fax:480-834-1136
Practice Address - Street 1:3638 E SOUTHERN AVE STE C108
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206-2564
Practice Address - Country:US
Practice Address - Phone:480-834-0771
Practice Address - Fax:480-834-1136
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2024-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AM0700X
AZ8487363AM0700X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ095004Medicaid
AZ095004Medicaid
GA003149992AMedicaid
NE269736Medicare PIN
GA003149992BMedicaid
R95858Medicare UPIN
GA003149992AMedicaid