Provider Demographics
NPI:1619075975
Name:NALL, CHAD (PA)
Entity Type:Individual
Prefix:MR
First Name:CHAD
Middle Name:
Last Name:NALL
Suffix:
Gender:M
Credentials:PA
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 9007
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65808-9007
Mailing Address - Country:US
Mailing Address - Phone:417-875-3000
Mailing Address - Fax:
Practice Address - Street 1:3555 S NATIONAL AVE FL 2
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-7310
Practice Address - Country:US
Practice Address - Phone:417-875-3800
Practice Address - Fax:417-875-3176
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2018-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005008043363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO220024489Medicaid