Basic Information
| Provider Information | |||||||||
| NPI: | 1609823079 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHAVEZ | ||||||||
| FirstName: | ERIC | ||||||||
| MiddleName: | MARTIN | ||||||||
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| Credential: | P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4024 | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 658084024 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4178853888 | ||||||||
| FaxNumber: | 4178817638 | ||||||||
| Practice Location | |||||||||
| Address1: | 3801 S NATIONAL AVE | ||||||||
| Address2: | WEST TOWER, SUITE 700 | ||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 658075210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4178853888 | ||||||||
| FaxNumber: | 4175205959 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/30/2006 | ||||||||
| LastUpdateDate: | 10/04/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 2010008194 | MO | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 2010008194 | 01 | MO | BOARD CERTIFIATION | OTHER | P01050641 | 01 | MO | MCR RR | OTHER | 431560263 | 01 | MO | TRICARE | OTHER |