Provider Demographics
NPI:1972673184
Name:PHYSICIAN ASSISTANT SERVICES OF FLORIDA LLC
Entity Type:Organization
Organization Name:PHYSICIAN ASSISTANT SERVICES OF FLORIDA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:HAMILTON
Authorized Official - Last Name:BOONE
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:321-409-8941
Mailing Address - Street 1:PO BOX 1261
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32902-1261
Mailing Address - Country:US
Mailing Address - Phone:321-409-8941
Mailing Address - Fax:321-409-9392
Practice Address - Street 1:301 E HIBISCUS BLVD
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-3105
Practice Address - Country:US
Practice Address - Phone:321-409-8941
Practice Address - Fax:321-409-9392
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-08
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA3525363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL=========OtherTIN
FL=========OtherTIN