Healthcare Provider Details

I. General information

NPI: 1659361780
Provider Name (Legal Business Name): TOM CHATHAM PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/28/2005
Last Update Date: 02/09/2022
Certification Date: 02/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1015 GROVE ST
MEADVILLE PA
16335-2905
US

IV. Provider business mailing address

1034 GROVE ST
MEADVILLE PA
16335-2945
US

V. Phone/Fax

Practice location:
  • Phone: 814-337-5894
  • Fax: 814-337-7082
Mailing address:
  • Phone: 814-337-5894
  • Fax: 814-337-7082

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberMA054111
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberOA000774
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: