Basic Information
| Provider Information | |||||||||
| NPI: | 1699702662 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WORLEY | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | B. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3725 MIDVALE AVE #4 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 90034 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3237263868 | ||||||||
| FaxNumber: | 3237263870 | ||||||||
| Practice Location | |||||||||
| Address1: | 3106 WEST BEVERLY BLVD | ||||||||
| Address2: | |||||||||
| City: | MONTEBELLO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 90640 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3237263868 | ||||||||
| FaxNumber: | 3237263870 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2006 | ||||||||
| LastUpdateDate: | 12/08/2009 | ||||||||
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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 | 363AM0700X | PA17689 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 95-4430908 | 01 | CA | TAX ID | OTHER | PA17689 | 05 | CA | MEDICAID |