Basic Information
| Provider Information | |||||||||
| NPI: | 1083005961 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MACDONALD | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | T | ||||||||
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| Credential: | APN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 715 HORIZON DR | ||||||||
| Address2: | SUITE 225 | ||||||||
| City: | GRAND JUNCTION | ||||||||
| State: | CO | ||||||||
| PostalCode: | 815068700 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 360 PEAK ONE DR | ||||||||
| Address2: | STE 110 | ||||||||
| City: | FRISCO | ||||||||
| State: | CO | ||||||||
| PostalCode: | 80443 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9706683478 | ||||||||
| FaxNumber: | 9706680632 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/12/2015 | ||||||||
| LastUpdateDate: | 08/03/2016 | ||||||||
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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 | 363LP0808X | APN.0992380-NP | CO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
No ID Information.