Individual
CHARLES J DAVIS
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PA-C
Contact information
Practice address
14410 SE PETROVITSKY RD STE 104, RENTON, WA 98058-8900
(425) 690-3405
(425) 690-9405
Mailing address
3600 LIND AVE SW, SUITE 100 ATTN CREDENTIALING, RENTON, WA 98057-4970
(425) 690-2715
Taxonomy
Speciality
Code
Description
License number
State
363AM0700X
Medical Physician Assistant
Primary
PA10004461
WA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1023188
—
WA
01
—
G8971468
MEDICARE W VALLEY MEDICAL GROUP - RENTON
WA
Enumeration date
07/20/2006
Last updated
03/31/2020
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