Healthcare Provider Details

I. General information

NPI: 1720285380
Provider Name (Legal Business Name): KEVIN MICHAEL CHANDON PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/28/2007
Last Update Date: 12/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

64 ROBBINS ST
WATERBURY CT
06708-2613
US

IV. Provider business mailing address

48 WALNUT ST
THOMASTON CT
06787-1540
US

V. Phone/Fax

Practice location:
  • Phone: 203-573-6000
  • Fax:
Mailing address:
  • Phone: 917-971-8350
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number011879
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number002550
License Number StateCT
# 3
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number002550
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: