Provider Demographics
NPI:1619648961
Name:EVANS, CHARLES CAMERON (PA)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:CAMERON
Last Name:EVANS
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 1:4445 S SEMORAN BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32822-2472
Mailing Address - Country:US
Mailing Address - Phone:407-203-8957
Mailing Address - Fax:407-985-1904
Practice Address - Street 1:4445 S SEMORAN BLVD STE A
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32822-2472
Practice Address - Country:US
Practice Address - Phone:407-203-8957
Practice Address - Fax:407-985-1904
Is Sole Proprietor?:No
Enumeration Date:2021-09-27
Last Update Date:2021-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9115058363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical