Healthcare Provider Details

I. General information

NPI: 1487617890
Provider Name (Legal Business Name): CHAD MICHAEL MOODY PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/07/2006
Last Update Date: 03/07/2022
Certification Date: 02/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2421 WORTH ST
HEMPHILL TX
75948-7215
US

IV. Provider business mailing address

2421 WORTH ST
HEMPHILL TX
75948-7215
US

V. Phone/Fax

Practice location:
  • Phone: 409-787-1416
  • Fax: 409-787-1419
Mailing address:
  • Phone: 409-787-1416
  • Fax: 409-787-1419

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA04719
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA04719
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: