Healthcare Provider Details

I. General information

NPI: 1316959216
Provider Name (Legal Business Name): CHARLES W TEVEBAUGH APN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2006
Last Update Date: 04/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12 E APPLEBY SUITE 101
FAYETTEVILLE AR
72703
US

IV. Provider business mailing address

12 E APPLEBY SUITE 101
FAYETTEVILLE AR
72703
US

V. Phone/Fax

Practice location:
  • Phone: 479-463-4444
  • Fax: 479-463-4499
Mailing address:
  • Phone: 479-463-4444
  • Fax: 479-463-4499

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberA01080
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: