Provider Demographics
NPI:1144267048
Name:STAATS, CHARLES LIONEL (PA)
Entity type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:LIONEL
Last Name:STAATS
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1105 CENTRAL EXPY N
Mailing Address - Street 2:STE 120
Mailing Address - City:ALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:75013-6103
Mailing Address - Country:US
Mailing Address - Phone:972-727-9995
Mailing Address - Fax:972-727-8350
Practice Address - Street 1:1105 CENTRAL EXPY N
Practice Address - Street 2:STE 120
Practice Address - City:ALLEN
Practice Address - State:TX
Practice Address - Zip Code:75013-6103
Practice Address - Country:US
Practice Address - Phone:972-727-9995
Practice Address - Fax:972-727-8350
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2013-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA01276363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX835N16OtherBC/BS TX - EFFECT. 02/01/2011
TXTXB121232OtherMEDICARE PART B EFFECT 02/01/2011
TX87N310OtherBCBS
TX6484850001Medicare NSC
83N817Medicare PIN
TXTXB121232OtherMEDICARE PART B EFFECT 02/01/2011
TX87N310OtherBCBS