Provider Demographics
NPI:1356329379
Name:CHAVEZ, KELLY D (PA-C)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:D
Last Name:CHAVEZ
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 1:2285 CORPORATE CIR
Mailing Address - Street 2:STE 200
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89074-7759
Mailing Address - Country:US
Mailing Address - Phone:702-360-2763
Mailing Address - Fax:949-783-2880
Practice Address - Street 1:1729 N TREKELL RD
Practice Address - Street 2:SUITE 124
Practice Address - City:CASA GRANDE
Practice Address - State:AZ
Practice Address - Zip Code:85222
Practice Address - Country:US
Practice Address - Phone:520-421-7100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-09
Last Update Date:2016-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPA2004-0001363A00000X
TXPA06592363A00000X
AZ4885363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM11435577Medicaid
AZP00990161OtherRR MEDICARE - AZ CASA GRANDE
AZZ130670 - CASAGRANDEMedicare PIN
AZP00990161OtherRR MEDICARE - AZ CASA GRANDE