Basic Information
| Provider Information | |||||||||
| NPI: | 1659625879 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WILLIAMS | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | IOKEPA | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | NP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1660 HIGHWAY 100 SOUTH | ||||||||
| Address2: | SUITE 145 | ||||||||
| City: | ST. LOUIS PARK | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554161562 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9524566160 | ||||||||
| FaxNumber: | 9524566184 | ||||||||
| Practice Location | |||||||||
| Address1: | 1660 HWY 100 SOUTH | ||||||||
| Address2: | SUITE 145 | ||||||||
| City: | ST. LOUIS PARK | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554161562 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9524566160 | ||||||||
| FaxNumber: | 9524566184 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/09/2012 | ||||||||
| LastUpdateDate: | 04/19/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | 166936-9 | MN | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 363LA2200X | R166936-9 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
ID Information
| ID | Type | State | Issuer | Description | 500008394 | 01 | MN | MEDICAL PTAN | OTHER | C09271 | 01 | MN | MEDICARE GROUP PTAN | OTHER |