Basic Information
| Provider Information | |||||||||
| NPI: | 1093734436 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHARLES | ||||||||
| FirstName: | SANDRA | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 HOSPITAL DR STE 306 | ||||||||
| Address2: | |||||||||
| City: | LEWISBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 178379350 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5705224110 | ||||||||
| FaxNumber: | 5707683911 | ||||||||
| Practice Location | |||||||||
| Address1: | 935 ROUTE 522 | ||||||||
| Address2: | |||||||||
| City: | SELINSGROVE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 178709714 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5703726102 | ||||||||
| FaxNumber: | 5703726110 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2006 | ||||||||
| LastUpdateDate: | 05/23/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/23/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | OS008937L | PA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 118438702 | 01 | PA | DEPARTMENT OF LABOR | OTHER | 0016096200008 | 05 | PA | MEDICAID | P00121999 | 01 | PA | RAILROAD MEDICARE | OTHER | 02185103 | 01 | PA | BLUE CROSS | OTHER | 232809429 | 01 | PA | TRICARE | OTHER | G38215 | 01 | PA | HEALTH AMERICA | OTHER | 02185103 | 01 | PA | KEYSTONE | OTHER | 15357C3AA | 01 | PA | GEISINGER | OTHER | 894313 | 01 | PA | BLUE SHIELD | OTHER |