Basic Information
| Provider Information | |||||||||
| NPI: | 1700439874 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WILLETT | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | HERBERT | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | BANNER MD ANDERSON CANCER CENTER | ||||||||
| Address2: | 2940 E. BANNER GATEWAY DR. STE 450 | ||||||||
| City: | GILBERT | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85234 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4802563613 | ||||||||
| FaxNumber: | 4802564734 | ||||||||
| Practice Location | |||||||||
| Address1: | BANNER MD ANDERSON CANCER CENTER | ||||||||
| Address2: | 2940 E. BANNER GATEWAY DR. STE 450 | ||||||||
| City: | GILBERT | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85234 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4802563613 | ||||||||
| FaxNumber: | 4802564734 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2019 | ||||||||
| LastUpdateDate: | 01/18/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/18/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363AS0400X | 8876 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
No ID Information.