=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801415625
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHASE JENTRY MCCLARD PA-C
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/12/2020
-----------------------------------------------------
Last Update Date | 12/09/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 300 S 8TH ST STE 480W
-----------------------------------------------------
City | MURRAY
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42071-2403
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-753-0704
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 14143
-----------------------------------------------------
City | BELFAST
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04915-4032
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-762-1321
-----------------------------------------------------
Fax | 270-767-3613
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number | PA2813
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------