Healthcare Provider Details

I. General information

NPI: 1043589419
Provider Name (Legal Business Name): CHAD EVENTIDE MHS, PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/14/2011
Last Update Date: 12/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 BRANSCOMB RD
LAYTONVILLE CA
95454
US

IV. Provider business mailing address

89 MILL CREEK DR
WILLITS CA
95490-3023
US

V. Phone/Fax

Practice location:
  • Phone: 707-984-6131
  • Fax:
Mailing address:
  • Phone: 919-381-2222
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: