Provider Demographics
NPI:1871928127
Name:CHARLES, MARY WAMPLER (PA-C)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:WAMPLER
Last Name:CHARLES
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:1315 S HOWARD AVE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33606-3193
Mailing Address - Country:US
Mailing Address - Phone:813-350-9090
Mailing Address - Fax:813-443-5783
Practice Address - Street 1:1315 S HOWARD AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33606-3193
Practice Address - Country:US
Practice Address - Phone:813-350-9090
Practice Address - Fax:813-443-5783
Is Sole Proprietor?:No
Enumeration Date:2013-09-05
Last Update Date:2014-03-24
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
FLPA9107425363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical