Provider Demographics
NPI:1013192046
Name:NUTTER, CARLA R (PA-C)
Entity Type:Individual
Prefix:
First Name:CARLA
Middle Name:R
Last Name:NUTTER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 MARTIN AVE STE 225
Mailing Address - Street 2:
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60540-6590
Mailing Address - Country:US
Mailing Address - Phone:630-355-5633
Mailing Address - Fax:630-355-5215
Practice Address - Street 1:10 MARTIN AVE STE 225
Practice Address - Street 2:
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60540-6590
Practice Address - Country:US
Practice Address - Phone:303-355-5633
Practice Address - Fax:630-355-5215
Is Sole Proprietor?:No
Enumeration Date:2008-01-09
Last Update Date:2021-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV00777363A00000X
IL085.006881363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV777OtherWV STATE LICENSES
WVWV2387Medicare PIN