Provider Demographics
NPI:1255308284
Name:CHARLES, JOHN GRAHAM (PA)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:GRAHAM
Last Name:CHARLES
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
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Mailing Address - Street 1:700 ZEAGLER DR
Mailing Address - Street 2:SUITE 8
Mailing Address - City:PALATKA
Mailing Address - State:FL
Mailing Address - Zip Code:32177-6806
Mailing Address - Country:US
Mailing Address - Phone:386-328-4242
Mailing Address - Fax:386-328-4244
Practice Address - Street 1:700 ZEAGLER DR
Practice Address - Street 2:SUITE 8
Practice Address - City:PALATKA
Practice Address - State:FL
Practice Address - Zip Code:32177-6806
Practice Address - Country:US
Practice Address - Phone:386-328-4242
Practice Address - Fax:386-328-4244
Is Sole Proprietor?:No
Enumeration Date:2006-03-08
Last Update Date:2016-08-16
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
FLPA9102210363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLQ11487Medicare UPIN