Healthcare Provider Details

I. General information

NPI: 1124136569
Provider Name (Legal Business Name): GERARD GEORGE CHISNALL R.P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

151 KNOLLCROFT RD
LYONS NJ
07939-5001
US

IV. Provider business mailing address

4864 CONCORD DR
EASTON PA
18045-8116
US

V. Phone/Fax

Practice location:
  • Phone: 908-647-0180
  • Fax: 908-604-5850
Mailing address:
  • Phone: 610-751-8817
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number23-00763
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: