Healthcare Provider Details

I. General information

NPI: 1942626155
Provider Name (Legal Business Name): ISMARY CHACON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/12/2014
Last Update Date: 03/12/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 NE 167TH ST
N MIAMI BEACH FL
33162-2304
US

IV. Provider business mailing address

1558 NW 159TH AVE
PEMBROKE PINES FL
33028-1696
US

V. Phone/Fax

Practice location:
  • Phone: 305-940-0522
  • Fax: 305-653-1138
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA9107555
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: