Healthcare Provider Details

I. General information

NPI: 1043295199
Provider Name (Legal Business Name): ROBERT PAUL NUTTER PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/13/2005
Last Update Date: 04/07/2020
Certification Date: 04/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2645 MERIDIAN PKWY STE 323
DURHAM NC
27713-4232
US

IV. Provider business mailing address

11050 MOUNT BELVEDERE BLVD USA MEDDAC ATTN: CREDENTIALS
FORT DRUM NY
13602-5438
US

V. Phone/Fax

Practice location:
  • Phone: 984-227-8902
  • Fax:
Mailing address:
  • Phone: 315-772-4025
  • Fax: 315-772-9498

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: