Provider Demographics
NPI:1053863746
Name:EMERSON, CHARLES (PA, ATC)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:EMERSON
Suffix:
Gender:M
Credentials:PA, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12553 BLUE LAGOON TRL
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32225-5221
Mailing Address - Country:US
Mailing Address - Phone:352-316-3224
Mailing Address - Fax:
Practice Address - Street 1:120 KING ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32204-2410
Practice Address - Country:US
Practice Address - Phone:904-253-2785
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-27
Last Update Date:2022-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT97201363A00000X
FLPA9109426363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant