Basic Information
| Provider Information | |||||||||
| NPI: | 1033441480 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TILLER | ||||||||
| FirstName: | CHAD | ||||||||
| MiddleName: | ETHAN | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 751274 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282751274 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7025602916 | ||||||||
| FaxNumber: | 7025602928 | ||||||||
| Practice Location | |||||||||
| Address1: | 10211 ALM ST | ||||||||
| Address2: | SUITE 1200 | ||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276178221 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9192064889 | ||||||||
| FaxNumber: | 9192064875 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/10/2010 | ||||||||
| LastUpdateDate: | 03/06/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA1197 | NV | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 0010-04010 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 1033441480 | 05 | NV | MEDICAID |