Basic Information
| Provider Information | |||||||||
| NPI: | 1184993784 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BELL | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | WESLEY | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 935 SHOTWELL RD | ||||||||
| Address2: | SUITE 108 | ||||||||
| City: | CLAYTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275205597 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9195500821 | ||||||||
| FaxNumber: | 9197193645 | ||||||||
| Practice Location | |||||||||
| Address1: | 5156 NC HIGHWAY 42 W | ||||||||
| Address2: | |||||||||
| City: | GARNER | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275298417 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9193295000 | ||||||||
| FaxNumber: | 9193295300 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/28/2011 | ||||||||
| LastUpdateDate: | 12/28/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 0010-03286 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 0010-03286 | 01 | NC | MEDICAL LICENSE | OTHER |