1356329379 NPI number — KELLY D CHAVEZ PA-C

Table of content: KELLY D CHAVEZ PA-C (NPI 1356329379)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356329379 NPI number — KELLY D CHAVEZ PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CHAVEZ
Provider First Name:
KELLY
Provider Middle Name:
D
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1356329379
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/13/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2285 CORPORATE CIR
Provider Second Line Business Mailing Address:
STE 200
Provider Business Mailing Address City Name:
HENDERSON
Provider Business Mailing Address State Name:
NV
Provider Business Mailing Address Postal Code:
89074-7759
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
702-360-2763
Provider Business Mailing Address Fax Number:
949-783-2880

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1729 N TREKELL RD
Provider Second Line Business Practice Location Address:
SUITE 124
Provider Business Practice Location Address City Name:
CASA GRANDE
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85222
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
520-421-7100
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/09/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  PA2004-0001 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: PA06592 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: 4885 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 11435577 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00990161 . This is a "RR MEDICARE - AZ CASA GRANDE" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".




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