Healthcare Provider Details

I. General information

NPI: 1588701700
Provider Name (Legal Business Name): CHARLES JAMES MCCLUSKEY PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/30/2007
Last Update Date: 02/27/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6500 66TH ST
PINELLAS PARK FL
33781-5030
US

IV. Provider business mailing address

6500 66TH STREET NORTH
PINELLAS PARK FL
33704-3537
US

V. Phone/Fax

Practice location:
  • Phone: 727-347-1286
  • Fax: 727-345-3084
Mailing address:
  • Phone: 727-347-1286
  • Fax: 727-384-8224

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA1840
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: