Provider Demographics
NPI:1639325376
Name:MOORE, CHARLENE K (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:CHARLENE
Middle Name:K
Last Name:MOORE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:CHARLENE
Other - Middle Name:K
Other - Last Name:SKUBOVIUS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:160 NW CENTRAL PARK PLZ STE 103
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34986-1825
Mailing Address - Country:US
Mailing Address - Phone:772-212-7636
Mailing Address - Fax:772-212-7625
Practice Address - Street 1:160 NW CENTRAL PARK PLZ STE 103
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34986-1825
Practice Address - Country:US
Practice Address - Phone:772-212-7636
Practice Address - Fax:772-212-7625
Is Sole Proprietor?:No
Enumeration Date:2008-08-13
Last Update Date:2022-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50002517363A00000X
FLPA9107673363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant