Provider Demographics
NPI:1871703405
Name:CHAVEZ, CAROL S (PA)
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:S
Last Name:CHAVEZ
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 229
Mailing Address - Street 2:
Mailing Address - City:PERALTA
Mailing Address - State:NM
Mailing Address - Zip Code:87042-0229
Mailing Address - Country:US
Mailing Address - Phone:505-866-1731
Mailing Address - Fax:
Practice Address - Street 1:1501 SAN PEDRO SE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87108
Practice Address - Country:US
Practice Address - Phone:505-265-1711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM95-PA03363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant