Basic Information
| Provider Information | |||||||||
| NPI: | 1629171293 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MISORI | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | ITOE | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | CRNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12201 BLUEGRASS PKWY | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402992361 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5025687366 | ||||||||
| FaxNumber: | 5025687114 | ||||||||
| Practice Location | |||||||||
| Address1: | 105 TEAKWOOD DR SW | ||||||||
| Address2: | |||||||||
| City: | HUNTSVILLE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 358013454 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2568815000 | ||||||||
| FaxNumber: | 2568818629 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/07/2006 | ||||||||
| LastUpdateDate: | 05/18/2015 | ||||||||
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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 | 363L00000X | 1094507 | AL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LF0000X | 1094507 | AL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.