Provider Demographics
NPI:1013187558
Name:RISTAU, CHAD MICHAEL
Entity Type:Individual
Prefix:MR
First Name:CHAD
Middle Name:MICHAEL
Last Name:RISTAU
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1746 KUNTZ RD
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16509-2642
Mailing Address - Country:US
Mailing Address - Phone:814-866-2684
Mailing Address - Fax:
Practice Address - Street 1:2 CRESCENT PARK WEST.
Practice Address - Street 2:WARREN GENERAL HOSPITAL
Practice Address - City:WARREN
Practice Address - State:PA
Practice Address - Zip Code:16365
Practice Address - Country:US
Practice Address - Phone:814-723-3300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-11
Last Update Date:2008-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN528488L367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered