Basic Information
| Provider Information | |||||||||
| NPI: | 1215287420 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MCCORD | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | KEITH | ||||||||
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| Credential: | P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1005 DR DB TODD JR BLVD | ||||||||
| Address2: | |||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372083501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153275944 | ||||||||
| FaxNumber: | 6153275597 | ||||||||
| Practice Location | |||||||||
| Address1: | 16850 BEAR VALLEY RD | ||||||||
| Address2: | |||||||||
| City: | VICTORVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923955794 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7602418000 | ||||||||
| FaxNumber: | 7609628021 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2012 | ||||||||
| LastUpdateDate: | 01/04/2019 | ||||||||
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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 | 363A00000X | PA22512 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.