Provider Demographics
NPI:1720182710
Name:CHARLTON, CODY RANDY (CRNA)
Entity Type:Individual
Prefix:MR
First Name:CODY
Middle Name:RANDY
Last Name:CHARLTON
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3570
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84110-3570
Mailing Address - Country:US
Mailing Address - Phone:801-727-2056
Mailing Address - Fax:770-701-6675
Practice Address - Street 1:801 W MAPLE ST
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-5630
Practice Address - Country:US
Practice Address - Phone:505-609-2258
Practice Address - Fax:505-609-2259
Is Sole Proprietor?:No
Enumeration Date:2006-09-11
Last Update Date:2021-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCRNA-01505367500000X
UT5130028-4406367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered