MEDICARE: MISTY LOVE CHASTAIN PAC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AM0700X	Medical Physician Assistant	103816	NC
2	363AM0700X	Medical Physician Assistant	2825	SC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	P99126	OTHER	NC	UPIN

General Provider Information

NPI Number	:	1790867117
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISTY LOVE CHASTAIN PAC

Provider Business Mailing Address
First Line	:	PO BOX 751461
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28275-1461
Country	:	US
Telephone Number	:	843-792-6200
Fax Number	:

Provider Business Practice Location Address
First Line	:	171 ASHLEY AVE
Second Line	:
City	:	CHARLESTON
State	:	SC
Zip	:	29425-7826
Country	:	US
Telephone Number	:	843-792-1414
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/19/2006
Last Update Date	:	09/18/2018

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Directions to “ MISTY LOVE CHASTAIN PAC” Practice Location

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