Provider Demographics
NPI:1821426883
Name:STANLEY, TABITHA CHARLESTON (PA-C)
Entity Type:Individual
Prefix:
First Name:TABITHA
Middle Name:CHARLESTON
Last Name:STANLEY
Suffix:
Gender:F
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 1:1008 E EMMA ST
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33603-4143
Mailing Address - Country:US
Mailing Address - Phone:407-580-9177
Mailing Address - Fax:
Practice Address - Street 1:3444 LITHIA PINECREST RD
Practice Address - Street 2:
Practice Address - City:VALRICO
Practice Address - State:FL
Practice Address - Zip Code:33596-6301
Practice Address - Country:US
Practice Address - Phone:813-643-9393
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-10-29
Last Update Date:2019-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9107584363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant