Basic Information
| Provider Information | |||||||||
| NPI: | 1063402634 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PARADISE | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | JOSEPH | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1333 E BARNETT RD | ||||||||
| Address2: | |||||||||
| City: | MEDFORD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975048219 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3618836211 | ||||||||
| FaxNumber: | 3618824891 | ||||||||
| Practice Location | |||||||||
| Address1: | 1333 E BARNETT RD | ||||||||
| Address2: | |||||||||
| City: | MEDFORD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975048219 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417794711 | ||||||||
| FaxNumber: | 5417790796 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2005 | ||||||||
| LastUpdateDate: | 07/31/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/31/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 691160 | TX | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367500000X | 202002199CRNA | OR | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.