Provider Demographics
NPI:1861999542
Name:CHARLES, BASHIRA (PHD, RN, CRNP)
Entity type:Individual
Prefix:DR
First Name:BASHIRA
Middle Name:
Last Name:CHARLES
Suffix:
Gender:F
Credentials:PHD, RN, CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:738 LANDIS ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19124-3011
Mailing Address - Country:US
Mailing Address - Phone:215-225-0325
Mailing Address - Fax:215-400-4173
Practice Address - Street 1:440 NORTH BROAD STREET
Practice Address - Street 2:STUDENT HEALTH SERVICES
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:10130-4015
Practice Address - Country:US
Practice Address - Phone:215-400-5704
Practice Address - Fax:215-400-4173
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-10
Last Update Date:2018-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP008021363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics