Provider Demographics
NPI:1073054862
Name:SKIDMORE, JUSTIN STUART (PA-C)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:STUART
Last Name:SKIDMORE
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3403 E KNOLLWOOD ST
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33610-1550
Mailing Address - Country:US
Mailing Address - Phone:863-267-4104
Mailing Address - Fax:
Practice Address - Street 1:3403 E KNOLLWOOD ST
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33610-1550
Practice Address - Country:US
Practice Address - Phone:863-267-4104
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-14
Last Update Date:2017-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9110082363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant