Healthcare Provider Details

I. General information

NPI: 1083005961
Provider Name (Legal Business Name): CHARLES T MACDONALD APN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/12/2015
Last Update Date: 08/03/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

360 PEAK ONE DR STE 110
FRISCO CO
80443
US

IV. Provider business mailing address

715 HORIZON DR SUITE 225
GRAND JUNCTION CO
81506-8700
US

V. Phone/Fax

Practice location:
  • Phone: 970-668-3478
  • Fax: 970-668-0632
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAPN.0992380-NP
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: