Healthcare Provider Details

I. General information

NPI: 1245609189
Provider Name (Legal Business Name): CHANDLER LARSEN YEAZITZIS PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/22/2015
Last Update Date: 11/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 SHIRCLIFF WAY
JACKSONVILLE FL
32204-4748
US

IV. Provider business mailing address

5700 SOUTHWYCK BLVD
TOLEDO OH
43614-1509
US

V. Phone/Fax

Practice location:
  • Phone: 904-308-7300
  • Fax:
Mailing address:
  • Phone: 800-288-8325
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9109042
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA9109042
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: