Provider Demographics
NPI:1902012966
Name:CHASE-BOUAMOUD, NINA C (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:NINA
Middle Name:C
Last Name:CHASE-BOUAMOUD
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:NINA
Other - Middle Name:
Other - Last Name:CHASE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5653 S HIGHWAY 95
Mailing Address - Street 2:
Mailing Address - City:FORT MOHAVE
Mailing Address - State:AZ
Mailing Address - Zip Code:86426-6068
Mailing Address - Country:US
Mailing Address - Phone:928-768-2558
Mailing Address - Fax:
Practice Address - Street 1:305 S LINE AVE
Practice Address - Street 2:
Practice Address - City:INVERNESS
Practice Address - State:FL
Practice Address - Zip Code:34452-4605
Practice Address - Country:US
Practice Address - Phone:352-344-4791
Practice Address - Fax:352-344-3822
Is Sole Proprietor?:No
Enumeration Date:2007-05-15
Last Update Date:2021-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5781363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPA9114448OtherMEDICAL LICENSE