Provider Demographics
NPI:1376594747
Name:SUTTON, ANTHONY CHARLES (PA-C)
Entity Type:Individual
Prefix:MR
First Name:ANTHONY
Middle Name:CHARLES
Last Name:SUTTON
Suffix:
Gender:M
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 1:9259 SVL BOX
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92395-5136
Mailing Address - Country:US
Mailing Address - Phone:760-951-0777
Mailing Address - Fax:
Practice Address - Street 1:12370 HESPERIA RD
Practice Address - Street 2:SUITE 6
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92395-7719
Practice Address - Country:US
Practice Address - Phone:760-245-4747
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2021-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601004165363A00000X
CAPA20735363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIM90900048Medicare PIN
MI0C96038055Medicare PIN