=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942556121
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHARLES MICHAEL KAYAT PA-C
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/25/2012
-----------------------------------------------------
Last Update Date | 09/03/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 300 TAMIAMI TRL S UNIT 1
-----------------------------------------------------
City | VENICE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34285-2422
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-303-5713
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 109 VENICE PALMS BLVD
-----------------------------------------------------
City | VENICE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34292-2446
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-777-7983
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | PA9106689
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------