Basic Information
| Provider Information | |||||||||
| NPI: | 1801029939 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CRESSELL | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | TRAVIS | ||||||||
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| Credential: | N.P. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1906 BELLEVIEW AVE SE | ||||||||
| Address2: | |||||||||
| City: | ROANOKE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 240141838 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5409817000 | ||||||||
| FaxNumber: | 5409831133 | ||||||||
| Practice Location | |||||||||
| Address1: | 1906 BELLEVIEW AVE SE | ||||||||
| Address2: | |||||||||
| City: | ROANOKE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 240141838 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5409817000 | ||||||||
| FaxNumber: | 5409831133 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/24/2009 | ||||||||
| LastUpdateDate: | 08/24/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 0024-168455 | VA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.