Basic Information
| Provider Information | |||||||||
| NPI: | 1316959216 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TEVEBAUGH | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | W | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | APN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12 E APPLEBY | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 72703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4794634444 | ||||||||
| FaxNumber: | 4794634499 | ||||||||
| Practice Location | |||||||||
| Address1: | 12 E APPLEBY | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 72703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4794634444 | ||||||||
| FaxNumber: | 4794634499 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/12/2006 | ||||||||
| LastUpdateDate: | 04/22/2011 | ||||||||
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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 | 363LG0600X | A01080 | AR | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology |
No ID Information.