Provider Demographics
NPI:1992505325
Name:POULSEN, CHASE RAYMOND II
Entity type:Individual
Prefix:
First Name:CHASE
Middle Name:RAYMOND
Last Name:POULSEN
Suffix:II
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5040 APPLERIDGE DR
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:SC
Mailing Address - Zip Code:29526-2376
Mailing Address - Country:US
Mailing Address - Phone:540-581-5759
Mailing Address - Fax:
Practice Address - Street 1:4350 US 421 S
Practice Address - Street 2:
Practice Address - City:LILLINGTON
Practice Address - State:NC
Practice Address - Zip Code:27546-6760
Practice Address - Country:US
Practice Address - Phone:480-034-4111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-14
Last Update Date:2025-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program