Provider Demographics
NPI:1376510560
Name:BYRON, CHARLES ALAN (PAC)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:ALAN
Last Name:BYRON
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4120 DEERPOINT LAKE DR
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32409-2164
Mailing Address - Country:US
Mailing Address - Phone:850-769-1668
Mailing Address - Fax:850-785-2123
Practice Address - Street 1:1900 HARRISON RD
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32405
Practice Address - Country:US
Practice Address - Phone:850-769-1668
Practice Address - Fax:850-785-2123
Is Sole Proprietor?:No
Enumeration Date:2006-03-07
Last Update Date:2014-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA3642363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE5077OtherBLUE CROSS
E50772Medicare ID - Type Unspecified
FLE5077OtherBLUE CROSS