Provider Demographics
NPI:1043589419
Name:EVENTIDE, CHAD (MHS, PA-C)
Entity Type:Individual
Prefix:
First Name:CHAD
Middle Name:
Last Name:EVENTIDE
Suffix:
Gender:M
Credentials:MHS, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:89 MILL CREEK DR
Mailing Address - Street 2:
Mailing Address - City:WILLITS
Mailing Address - State:CA
Mailing Address - Zip Code:95490-3023
Mailing Address - Country:US
Mailing Address - Phone:919-381-2222
Mailing Address - Fax:
Practice Address - Street 1:50 BRANSCOMB RD
Practice Address - Street 2:
Practice Address - City:LAYTONVILLE
Practice Address - State:CA
Practice Address - Zip Code:95454
Practice Address - Country:US
Practice Address - Phone:707-984-6131
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-14
Last Update Date:2011-12-14
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant