Healthcare Provider Details

I. General information

NPI: 1376625079
Provider Name (Legal Business Name): CHAD DERRICK MACNAUGHTON DC, FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/20/2006
Last Update Date: 01/04/2022
Certification Date: 01/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13 CHESTER ST
GLENS FALLS NY
12801-2913
US

IV. Provider business mailing address

13 CHESTER ST
GLENS FALLS NY
12801-2913
US

V. Phone/Fax

Practice location:
  • Phone: 518-223-0331
  • Fax: 518-223-0331
Mailing address:
  • Phone: 518-223-0331
  • Fax: 518-223-0331

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF348808-01
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberX0101611
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: