Healthcare Provider Details

I. General information

NPI: 1114979135
Provider Name (Legal Business Name): EDWARD C SKIBA PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2006
Last Update Date: 11/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 SE OCEAN BLVD
STUART FL
34996-3332
US

IV. Provider business mailing address

2100 SE OCEAN BLVD
STUART FL
34996-3332
US

V. Phone/Fax

Practice location:
  • Phone: 772-223-2115
  • Fax: 772-223-0887
Mailing address:
  • Phone: 772-223-2115
  • Fax: 772-223-0887

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA9101166
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: