Provider Demographics
NPI:1023199221
Name:SUNDQUIST, CHAD ERIC (PA-C)
Entity Type:Individual
Prefix:MR
First Name:CHAD
Middle Name:ERIC
Last Name:SUNDQUIST
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1416 E A ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82601-2276
Mailing Address - Country:US
Mailing Address - Phone:307-577-8600
Mailing Address - Fax:307-577-8605
Practice Address - Street 1:1416 E A ST
Practice Address - Street 2:SUITE 101
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82601-2276
Practice Address - Country:US
Practice Address - Phone:307-577-8600
Practice Address - Fax:307-577-8605
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2016-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYTL398363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00611278OtherMEDICARE RAILROAD
WY21008Medicare PIN
WYQ74073Medicare UPIN