Basic Information
| Provider Information | |||||||||
| NPI: | 1902300601 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DWYER | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | DANIEL | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | |||||||||
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| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1757 WALLER ST | ||||||||
| Address2: | |||||||||
| City: | SAN FRANCISCO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 941172727 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4156680494 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1757 WALLER ST | ||||||||
| Address2: | |||||||||
| City: | SAN FRANCISCO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 941172727 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4156680494 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/19/2018 | ||||||||
| LastUpdateDate: | 03/19/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 172V00000X | Y | Other Service Providers | Community Health Worker |
No ID Information.