Provider Demographics
NPI:1285459388
Name:CHEATHAM, CHELSEY DENAE (PA-C)
Entity type:Individual
Prefix:
First Name:CHELSEY
Middle Name:DENAE
Last Name:CHEATHAM
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1109 E BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:CUERO
Mailing Address - State:TX
Mailing Address - Zip Code:77954-2108
Mailing Address - Country:US
Mailing Address - Phone:361-275-2800
Mailing Address - Fax:361-275-8791
Practice Address - Street 1:1109 E BROADWAY ST
Practice Address - Street 2:
Practice Address - City:CUERO
Practice Address - State:TX
Practice Address - Zip Code:77954-2108
Practice Address - Country:US
Practice Address - Phone:361-275-2800
Practice Address - Fax:361-275-8791
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-22
Last Update Date:2024-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA18478363A00000X
CAPA65238363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant