Provider Demographics
NPI:1932170578
Name:ITH, CHAD VIRIYA (PAC)
Entity Type:Individual
Prefix:MR
First Name:CHAD
Middle Name:VIRIYA
Last Name:ITH
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:MR
Other - First Name:SOCHEAT
Other - Middle Name:
Other - Last Name:ITH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:710 LAWRENCE EXPY
Mailing Address - Street 2:DEPT 148
Mailing Address - City:SANTA CLARA
Mailing Address - State:CA
Mailing Address - Zip Code:95051-5173
Mailing Address - Country:US
Mailing Address - Phone:408-851-1850
Mailing Address - Fax:408-851-1871
Practice Address - Street 1:710 LAWRENCE EXPY
Practice Address - Street 2:DEPT 148
Practice Address - City:SANTA CLARA
Practice Address - State:CA
Practice Address - Zip Code:95051-5173
Practice Address - Country:US
Practice Address - Phone:408-851-1850
Practice Address - Fax:408-851-1871
Is Sole Proprietor?:No
Enumeration Date:2006-01-31
Last Update Date:2022-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA18527363A00000X
CT001611363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001611OtherPA LICENSE
CT004236007Medicaid
CT37374OtherCONTROLLED SUBSTANCE