Provider Demographics
NPI:1023652997
Name:MCCUTCHEON, CHARLES TRACY (APRN)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:TRACY
Last Name:MCCUTCHEON
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13131 NW 11TH DR
Mailing Address - Street 2:
Mailing Address - City:SUNRISE
Mailing Address - State:FL
Mailing Address - Zip Code:33323-2953
Mailing Address - Country:US
Mailing Address - Phone:954-695-5677
Mailing Address - Fax:
Practice Address - Street 1:13131 NW 11TH DR
Practice Address - Street 2:
Practice Address - City:SUNRISE
Practice Address - State:FL
Practice Address - Zip Code:33323-2953
Practice Address - Country:US
Practice Address - Phone:954-695-5677
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-04
Last Update Date:2019-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11003236363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily