Healthcare Provider Details

I. General information

NPI: 1033441480
Provider Name (Legal Business Name): CHAD ETHAN TILLER PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/10/2010
Last Update Date: 03/06/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10211 ALM ST SUITE 1200
RALEIGH NC
27617-8221
US

IV. Provider business mailing address

PO BOX 751274
CHARLOTTE NC
28275-1274
US

V. Phone/Fax

Practice location:
  • Phone: 919-206-4889
  • Fax: 919-206-4875
Mailing address:
  • Phone: 702-560-2916
  • Fax: 702-560-2928

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA1197
License Number StateNV
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0010-04010
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: