Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363L00000X | Nurse Practitioner | 71009184A | IN |
NPI | 1003477647 |
---|---|
Provider Name | Charles A Jones |
First Address | Fort Wayne, IN 46845-1701 |
Second Address | Fort Wayne, IN 46845-2204 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 25/06/2019 |
Last Update Date | 11/08/2021 |