Provider Demographics
NPI:1033441480
Name:TILLER, CHAD ETHAN (PA-C)
Entity Type:Individual
Prefix:
First Name:CHAD
Middle Name:ETHAN
Last Name:TILLER
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:PO BOX 751274
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1274
Mailing Address - Country:US
Mailing Address - Phone:702-560-2916
Mailing Address - Fax:702-560-2928
Practice Address - Street 1:10211 ALM ST
Practice Address - Street 2:SUITE 1200
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27617-8221
Practice Address - Country:US
Practice Address - Phone:919-206-4889
Practice Address - Fax:919-206-4875
Is Sole Proprietor?:No
Enumeration Date:2010-02-10
Last Update Date:2013-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVPA1197363A00000X
NC0010-04010363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1033441480Medicaid
NV1033441480Medicaid
NVDD165ZMedicare PIN