Charles Joseph Clancy, PA-C

Primary specialty

Physician AssistantTaxonomy code 363A00000X

License

PA9103700 Issued in FL

Practice address

1005 Mar Walt Dr
Immediate Care Department
Fort Walton Beach, FL 32547-6707

Phone

(850) 863-8219

Fax

(850) 863-8249

NPI assigned

Jun 2, 2006

Last updated

Nov 15, 2010By the provider in NPPES

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Addresses

Other identifiers 1

Medicare fee-for-service enrollment

Enrolled in FL

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: No

Green means eligible to order or refer.

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

Credentials

Physician Assistant

State licenses

Practice roles

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

• Crestview Urgent Care, Inc.

  • Urgent Care Clinic/Center
  • Crestview, FL
  • NPI 1144458647
  Medicare reassignment Authorized official
• Coastal Radiology Associates PA

  • Diagnostic Radiology Physician
  • Fort Walton Beach, FL
  • NPI 1750524393
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1149206400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1289779200000",
    "number": "1669410924",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1005 MAR WALT DRIVE",
            "address_2": "IMMEDIATE CARE DEPARTMENT",
            "city": "FORT WALTON BEACH",
            "state": "FL",
            "postal_code": "325476796",
            "telephone_number": "850-863-8219",
            "fax_number": "850-863-8249"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1005 MAR WALT DR",
            "address_2": "IMMEDIATE CARE DEPARTMENT",
            "city": "FORT WALTON BEACH",
            "state": "FL",
            "postal_code": "325476707",
            "telephone_number": "850-863-8219",
            "fax_number": "850-863-8249"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "CLANCY",
        "first_name": "CHARLES",
        "middle_name": "JOSEPH",
        "credential": "PA-C",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2006-06-02",
        "last_updated": "2010-11-15",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "FL",
            "license": "PA9103700",
            "primary": true
        },
        {
            "code": "207P00000X",
            "taxonomy_group": "",
            "desc": "Emergency Medicine",
            "state": "FL",
            "license": "PA9103700",
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "292457900",
            "state": "FL"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Patricia S Christie, ARNP
• Melissa Chrites
• Michelle L Chumbley, RBT
• Caitlin Bria Chumley, PTA
• Thomas Carton Church, M.D.
• Nancy Danielle Clancy
• Emily Clark, DPT
• Justin Clark, D.O.
• Rhonda D Clark, CRNA
• Tony D Clark, D.M.D.

• Physician Assistant in Fort Walton Beach, FL
• Providers in Fort Walton Beach, FL by specialty
• Physician Assistant in Florida

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 15, 2010; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.