Basic Information
| Provider Information | |||||||||
| NPI: | 1689661050 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | AINGE | ||||||||
| FirstName: | CHARLOTTE | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | PAC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | AINGE | ||||||||
| OtherFirstName: | TUCK | ||||||||
| OtherMiddleName: | STELLA | ||||||||
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| OtherCredential: | PAC | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 700 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | MOSCOW | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838433046 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2088824511 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 156 N. 6TH ST | ||||||||
| Address2: | |||||||||
| City: | POTLATCH | ||||||||
| State: | ID | ||||||||
| PostalCode: | 83855 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2088752380 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/30/2005 | ||||||||
| LastUpdateDate: | 04/16/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA449 | ID | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 000010149468 | 01 | ID | REGENCE BS OF ID | OTHER | 0195084 | 01 | WA | DEPT OF LABOR & INDUSTRY | OTHER | 8325052 | 05 | WA | MEDICAID | PAUS3 | 01 | ID | BLUE CROSS OF ID | OTHER | 806474000 | 05 | ID | MEDICAID |