Provider Demographics
NPI:1245329648
Name:DEAN, CHARLES L (PA)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:L
Last Name:DEAN
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 1:1301 W 18TH ST
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57105-0401
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1301 W 18TH ST
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57105-0401
Practice Address - Country:US
Practice Address - Phone:605-312-2200
Practice Address - Fax:605-312-2205
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2023-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0956363A00000X
MO2006031509363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200406410AMedicaid
MO214924OtherANTHEM
MO220083022Medicaid
P00350032OtherRR MEDICARE
OK200096650AMedicaid
MO000097353Medicare PIN