Basic Information
Provider Information | |||||||||
NPI: | 1518115658 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CHUT | ||||||||
FirstName: | NYAHON | ||||||||
MiddleName: | CHIENG | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 621 S ILLINOIS AVE STE 103 | ||||||||
Address2: |   | ||||||||
City: | MASON CITY | ||||||||
State: | IA | ||||||||
PostalCode: | 504015489 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6414283041 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2440 BRIDGE AVE | ||||||||
Address2: |   | ||||||||
City: | ALBERT LEA | ||||||||
State: | MN | ||||||||
PostalCode: | 560072088 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5073207900 | ||||||||
FaxNumber: | 5073207910 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/03/2008 | ||||||||
LastUpdateDate: | 08/15/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/15/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 1187 | MN | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
ID Information
ID | Type | State | Issuer | Description | 1518115658 | 01 | MN | MMSI | OTHER | 1518115658 | 01 | MN | BLUE CROSS & BLUE SHIELD OF MN | OTHER | 1518115658 | 01 | MN | HEALTH PARTNERS | OTHER | 1518115658 | 01 | MN | MEDICA | OTHER | 1518115658 | 01 | MN | PREFERRED ONE | OTHER | 1518115658 | 05 | MN |   | MEDICAID |