Basic Information
| Provider Information | |||||||||
| NPI: | 1114979135 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SKIBA | ||||||||
| FirstName: | EDWARD | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2100 SE OCEAN BLVD | ||||||||
| Address2: | |||||||||
| City: | STUART | ||||||||
| State: | FL | ||||||||
| PostalCode: | 349963332 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7722232115 | ||||||||
| FaxNumber: | 7722230887 | ||||||||
| Practice Location | |||||||||
| Address1: | 2100 SE OCEAN BLVD | ||||||||
| Address2: | |||||||||
| City: | STUART | ||||||||
| State: | FL | ||||||||
| PostalCode: | 349963332 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7722232115 | ||||||||
| FaxNumber: | 7722230887 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2006 | ||||||||
| LastUpdateDate: | 11/08/2011 | ||||||||
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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 | 363AM0700X | PA9101166 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 039775000 | 05 | FL | MEDICAID | Y00V3 | 01 | FL | BCBS OF FLORIDA | OTHER |