Provider Demographics
NPI:1295820967
Name:WEBSTER, CHARLES E (PA)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:E
Last Name:WEBSTER
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3475 S SUNCOAST BLVD
Mailing Address - Street 2:
Mailing Address - City:HOMOSASSA
Mailing Address - State:FL
Mailing Address - Zip Code:34448-2322
Mailing Address - Country:US
Mailing Address - Phone:352-628-7671
Mailing Address - Fax:352-628-9893
Practice Address - Street 1:3475 S SUNCOAST BLVD
Practice Address - Street 2:
Practice Address - City:HOMOSASSA
Practice Address - State:FL
Practice Address - Zip Code:34448-2322
Practice Address - Country:US
Practice Address - Phone:352-628-7671
Practice Address - Fax:352-628-9893
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2008-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA1866363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL060476301Medicaid
FL591842276001OtherTRICARE
FLE3069ZMedicare ID - Type UnspecifiedPROVIDER
FL060476301Medicaid