Healthcare Provider Details

I. General information

NPI: 1841549581
Provider Name (Legal Business Name): MICHAEL JOHN CHILLO RPA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2012
Last Update Date: 08/10/2022
Certification Date: 08/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

259 1ST ST
MINEOLA NY
11501-3957
US

IV. Provider business mailing address

259 1ST ST
MINEOLA NY
11501-3957
US

V. Phone/Fax

Practice location:
  • Phone: 516-663-2384
  • Fax:
Mailing address:
  • Phone: 516-663-2384
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number015897
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: