NPIMap

Individual provider Active NPI

Charles J Davis, PA-C

  • Medical Physician Assistant
  • Renton, WA
National Provider Identifier
1962422956
Registry record updated Mar 31, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Medical Physician AssistantTaxonomy code 363AM0700X
License
PA10004461 Issued in WA
Practice address
14410 SE Petrovitsky Rd Ste 104
Renton, WA 98058-8900
Phone
(425) 690-3405
Fax
(425) 690-9405
NPI assigned
Jul 20, 2006
Last updated
Mar 31, 2020By the provider in NPPES
Sex
Male
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Mar 31, 2020

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Medical Physician Assistant 363AM0700X PA10004461 WA Primary

Addresses

Primary practice location

14410 SE Petrovitsky Rd Ste 104
Renton, WA 98058-8900

Mailing address

3600 Lind Ave SW
Suite 100 Attn Credentialing
Renton, WA 98057-4970
Phone (425) 690-2715

Other identifiers 2

IdentifierTypeStateIssuer
1023188MedicaidWA
G8971468OtherWAMEDICARE W VALLEY MEDICAL GROUP - RENTON

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in WA
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20080122000171 WA Practitioner - Physician Assistant 7719068386 Reassigns benefits to 1 organization

Care Compare profile

Medicare Care Compare
Specialty
Physician Assistant
Education
Other, 2002
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Telehealth
Offers telehealth services
Group practices
Valley Medical Group-RentonGroup PAC ID 4183753965, 419 clinicians

Practice addresses (Care Compare)

14410 SE Petrovitsky Rd
Suite 104
Renton, WA 98058-8900
Phone (425) 656-4242

16850 SE 272ND St
Covington, WA 98042-4931

Hospital & facility affiliations

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Physician Assistant

State licenses

LicenseStateTypeSpecialty
PA10004461WAMDMedical Physician Assistant

Practice roles

OrganizationSpecialtyStatusNew patients
Harkness Medical Group, PLLC PastSince Apr 1, 2021 Accepting new patients
Public Hospital District #1 of King County Past Accepting new patients
Pacific Primary Care PC PastSince Mar 1, 2002 Accepting new patients

Interoperability endpoints

  • Direct secure messaging: cdavis68594@direct.valleymed.org

Organizations & group practices 4

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

Hospital & facility affiliations 4

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1153353600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1585612800000",
    "number": "1962422956",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3600 LIND AVE SW",
            "address_2": "SUITE 100 ATTN CREDENTIALING",
            "city": "RENTON",
            "state": "WA",
            "postal_code": "980574970",
            "telephone_number": "425-690-2715"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "14410 SE PETROVITSKY RD STE 104",
            "city": "RENTON",
            "state": "WA",
            "postal_code": "980588900",
            "telephone_number": "425-690-3405",
            "fax_number": "425-690-9405"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "DAVIS",
        "first_name": "CHARLES",
        "middle_name": "J",
        "credential": "PA-C",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2006-07-20",
        "last_updated": "2020-03-31",
        "certification_date": "2020-03-31",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363AM0700X",
            "taxonomy_group": "",
            "desc": "Physician Assistant, Medical",
            "state": "WA",
            "license": "PA10004461",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1023188",
            "state": "WA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICARE W VALLEY MEDICAL GROUP - RENTON",
            "identifier": "G8971468",
            "state": "WA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Renton, WA

Sources for this page

Verify at the official NPI Registry.