Individual
JERALD DIETRICH CHARLES
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PA-C
Contact information
Practice address
2845 GREENBRIER RD, GREEN BAY, WI 54311-6519
(920) 288-8320
Mailing address
164 N. BROADWAY, GREEN BAY, WI 54303-2728
(920) 490-9046
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
4028-023
WI
363AS0400X
Surgical Physician Assistant
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
100068010
—
WI
Enumeration date
02/13/2017
Last updated
12/14/2021
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