Healthcare Provider Details

I. General information

NPI: 1013192046
Provider Name (Legal Business Name): CARLA R. NUTTER PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/09/2008
Last Update Date: 03/02/2021
Certification Date: 02/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 MARTIN AVE STE 225
NAPERVILLE IL
60540-6590
US

IV. Provider business mailing address

10 MARTIN AVE STE 225
NAPERVILLE IL
60540-6590
US

V. Phone/Fax

Practice location:
  • Phone: 303-355-5633
  • Fax: 630-355-5215
Mailing address:
  • Phone: 630-355-5633
  • Fax: 630-355-5215

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number00777
License Number StateWV
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085.006881
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: