Healthcare Provider Details

I. General information

NPI: 1144645466
Provider Name (Legal Business Name): KEVIN CHIAPPONE P.A.-C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/24/2014
Last Update Date: 11/06/2020
Certification Date: 11/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

990 NW CIRCLE BLVD STE 102
CORVALLIS OR
97330-1967
US

IV. Provider business mailing address

PO BOX 1189
CORVALLIS OR
97339-1189
US

V. Phone/Fax

Practice location:
  • Phone: 541-768-5486
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number51461
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA167457
License Number StateOR
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA167457
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: