Basic Information
| Provider Information | |||||||||
| NPI: | 1508119736 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MINN | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | K | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1708 YAKIMA AVE | ||||||||
| Address2: | STE 107 | ||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984055307 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2532725881 | ||||||||
| FaxNumber: | 2533830161 | ||||||||
| Practice Location | |||||||||
| Address1: | 1708 YAKIMA AVE | ||||||||
| Address2: | STE 107 | ||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984055307 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2532725881 | ||||||||
| FaxNumber: | 2533830161 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2012 | ||||||||
| LastUpdateDate: | 10/25/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/25/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | P7514 | TX | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RN0300X | P7514 | TX | N | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology | 207RN0300X | MD60566032 | WA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
| ID | Type | State | Issuer | Description | 349638 | 01 | WA | STATE L&I | OTHER |