Basic Information
| Provider Information | |||||||||
| NPI: | 1144293648 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCNUTT | ||||||||
| FirstName: | CHARLTON | ||||||||
| MiddleName: | BRYAN | ||||||||
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| Credential: | ANP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 150 KENNETH FORD DRIVE | ||||||||
| Address2: | |||||||||
| City: | ROSEBURG | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974701042 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5416729596 | ||||||||
| FaxNumber: | 5414643519 | ||||||||
| Practice Location | |||||||||
| Address1: | 150 KENNETH FORD DRIVE | ||||||||
| Address2: | |||||||||
| City: | ROSEBURG | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974701042 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5416729596 | ||||||||
| FaxNumber: | 5414643519 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/07/2006 | ||||||||
| LastUpdateDate: | 09/10/2012 | ||||||||
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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 | 207Q00000X | 38225N3 | OR | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 168395 | 05 | OR | MEDICAID | R103163 | 01 | MEDICARE PART B | OTHER |