=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962221283
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PHARES CHARLES PA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/03/2024
-----------------------------------------------------
Last Update Date | 10/03/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3822 BROADWAY STE A
-----------------------------------------------------
City | FORT MYERS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33901-8148
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-900-9170
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 630 ROYAL PALM DR
-----------------------------------------------------
City | LAKE WORTH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33460-4757
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 781-535-2779
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number | 001884-PA
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------