Basic Information
| Provider Information | |||||||||
| NPI: | 1912156407 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GADE | ||||||||
| FirstName: | CHINNAPA | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1000 W CANNON ST | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761043029 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8177257900 | ||||||||
| FaxNumber: | 6822071030 | ||||||||
| Practice Location | |||||||||
| Address1: | 1001 PENNSYLVANIA AVE | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761042228 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8178775858 | ||||||||
| FaxNumber: | 8173354418 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/09/2008 | ||||||||
| LastUpdateDate: | 09/02/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/02/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 041368825 | IL | N | Nursing Service Providers | Registered Nurse | 363L00000X | AP129918 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | AP129918 | 01 | TX | ADVANCED PRACTICE NURSE LICENSE | OTHER | 041368825 | 01 | IL | IL DEPARTMENT OF PROFESSIONAL REGULATION | OTHER |