Provider Demographics
NPI:1609823079
Name:CHAVEZ, ERIC MARTIN (PA)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:MARTIN
Last Name:CHAVEZ
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 4024
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65808-4024
Mailing Address - Country:US
Mailing Address - Phone:417-885-3888
Mailing Address - Fax:417-881-7638
Practice Address - Street 1:3801 S NATIONAL AVE
Practice Address - Street 2:WEST TOWER, SUITE 700
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-5210
Practice Address - Country:US
Practice Address - Phone:417-885-3888
Practice Address - Fax:417-520-5959
Is Sole Proprietor?:No
Enumeration Date:2006-05-30
Last Update Date:2021-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010008194363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2010008194OtherBOARD CERTIFIATION
MOP01050641OtherMCR RR
MO431560263OtherTRICARE