Provider Demographics
NPI:1669410924
Name:CLANCY, CHARLES JOSEPH (PA-C)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:JOSEPH
Last Name:CLANCY
Suffix:
Gender:M
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 1:1005 MAR WALT DRIVE
Mailing Address - Street 2:IMMEDIATE CARE DEPARTMENT
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32547-6796
Mailing Address - Country:US
Mailing Address - Phone:850-863-8219
Mailing Address - Fax:850-863-8249
Practice Address - Street 1:1005 MAR WALT DR
Practice Address - Street 2:IMMEDIATE CARE DEPARTMENT
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547-6707
Practice Address - Country:US
Practice Address - Phone:850-863-8219
Practice Address - Fax:850-863-8249
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2010-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9103700363A00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL292457900Medicaid
FL292457900Medicaid