Provider Demographics
NPI:1326017757
Name:KRONENTHAL, CHARLES P JR (PA-C)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:P
Last Name:KRONENTHAL
Suffix:JR
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 1:14690 SPRING HILL DR STE 305
Mailing Address - Street 2:
Mailing Address - City:SPRING HILL
Mailing Address - State:FL
Mailing Address - Zip Code:34609-8102
Mailing Address - Country:US
Mailing Address - Phone:352-277-5348
Mailing Address - Fax:352-606-2857
Practice Address - Street 1:6279 N LECANTO HWY
Practice Address - Street 2:
Practice Address - City:BEVERLY HILLS
Practice Address - State:FL
Practice Address - Zip Code:34465-2503
Practice Address - Country:US
Practice Address - Phone:352-522-0094
Practice Address - Fax:352-522-0098
Is Sole Proprietor?:No
Enumeration Date:2006-03-17
Last Update Date:2019-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA 9104143363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000694000Medicaid
FL59-3682760OtherTRI CARE
FLAD950ZMedicare PIN
FL59-3682760OtherTRI CARE
FL000694000Medicaid