Provider Demographics
NPI:1356470983
Name:CHASE, VERNON A (DR)
Entity Type:Individual
Prefix:DR
First Name:VERNON
Middle Name:A
Last Name:CHASE
Suffix:
Gender:M
Credentials:DR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1309 CARROLLVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:BALDWYN
Mailing Address - State:MS
Mailing Address - Zip Code:38824-1112
Mailing Address - Country:US
Mailing Address - Phone:601-365-7721
Mailing Address - Fax:
Practice Address - Street 1:176 S MAIN ST
Practice Address - Street 2:
Practice Address - City:PONTOTOC
Practice Address - State:MS
Practice Address - Zip Code:38863-3311
Practice Address - Country:US
Practice Address - Phone:662-488-7640
Practice Address - Fax:662-488-7675
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS05771146N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes146N00000XEmergency Medical Service ProvidersEmergency Medical Technician, Basic
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS12626Medicaid
MS12626Medicaid