Basic Information
| Provider Information | |||||||||
| NPI: | 1861028284 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CUTSHAW | ||||||||
| FirstName: | KENENTH | ||||||||
| MiddleName: | ANDREW | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 621 COPPERLINE DR | ||||||||
| Address2: | |||||||||
| City: | CHAPEL HILL | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275164467 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4043125580 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 101 MANNING DR | ||||||||
| Address2: | |||||||||
| City: | CHAPEL HILL | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275144220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9849741000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/17/2020 | ||||||||
| LastUpdateDate: | 03/17/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/17/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.