Basic Information
Provider Information | |||||||||
NPI: | 1275278996 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DUNGAN | ||||||||
FirstName: | CHARLES | ||||||||
MiddleName: | MELVIN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | FNP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1510 HONEYSUCKLE AVE | ||||||||
Address2: |   | ||||||||
City: | MEDFORD | ||||||||
State: | OR | ||||||||
PostalCode: | 975045560 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5417896460 | ||||||||
FaxNumber: | 5417896461 | ||||||||
Practice Location | |||||||||
Address1: | 691 MURPHY RD STE 107 | ||||||||
Address2: |   | ||||||||
City: | MEDFORD | ||||||||
State: | OR | ||||||||
PostalCode: | 975044311 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5417896460 | ||||||||
FaxNumber: | 5417896461 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/28/2022 | ||||||||
LastUpdateDate: | 10/24/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/24/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WS0200X | 200541311RN | OR | N |   | Nursing Service Providers | Registered Nurse | School | 363LF0000X | 202210480NP | OR | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.