Basic Information
| Provider Information | |||||||||
| NPI: | 1376510560 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BYRON | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | ALAN | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4120 DEERPOINT LAKE DR | ||||||||
| Address2: | |||||||||
| City: | PANAMA CITY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 324092164 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8507691668 | ||||||||
| FaxNumber: | 8507852123 | ||||||||
| Practice Location | |||||||||
| Address1: | 1900 HARRISON RD | ||||||||
| Address2: | |||||||||
| City: | PANAMA CITY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 32405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8507691668 | ||||||||
| FaxNumber: | 8507852123 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/07/2006 | ||||||||
| LastUpdateDate: | 05/08/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA3642 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | E5077 | 01 | FL | BLUE CROSS | OTHER |