Provider Demographics
NPI:1891801171
Name:STRADER, CHARLES JACOB JR (PAC)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:JACOB
Last Name:STRADER
Suffix:JR
Gender:M
Credentials:PAC
Other - Prefix:
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Mailing Address - Street 1:11929 HEATHER WOODS CT
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34120
Mailing Address - Country:US
Mailing Address - Phone:865-599-2163
Mailing Address - Fax:865-694-7907
Practice Address - Street 1:621 NW 53RD ST
Practice Address - Street 2:SUITE 330
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33487
Practice Address - Country:US
Practice Address - Phone:800-488-0279
Practice Address - Fax:865-560-8525
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2019-09-19
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
TNPA9108754363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
3669657Medicare PIN
P00864Medicare UPIN
TN0677340001Medicare NSC