Provider Demographics
NPI:1003522657
Name:CUBBAGE, CHARLI ELIZABETH (PA)
Entity Type:Individual
Prefix:
First Name:CHARLI
Middle Name:ELIZABETH
Last Name:CUBBAGE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:88 BLUE STREAM WAY APT 11302
Mailing Address - Street 2:
Mailing Address - City:INLET BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32461-8633
Mailing Address - Country:US
Mailing Address - Phone:601-765-7277
Mailing Address - Fax:
Practice Address - Street 1:15415 PANAMA CITY BEACH PKWY
Practice Address - Street 2:
Practice Address - City:PANAMA CITY BEACH
Practice Address - State:FL
Practice Address - Zip Code:32413-5409
Practice Address - Country:US
Practice Address - Phone:850-588-3589
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-26
Last Update Date:2023-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSTUDENT363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant