Healthcare Provider Details

I. General information

NPI: 1104817568
Provider Name (Legal Business Name): KAMAL A CHANTAL PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/03/2005
Last Update Date: 10/10/2025
Certification Date: 10/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 CANDLEWOOD CT
LYNCHBURG VA
24502-2654
US

IV. Provider business mailing address

801 YORK ST
MANITOWOC WI
54220-4630
US

V. Phone/Fax

Practice location:
  • Phone: 434-363-4190
  • Fax: 434-363-4191
Mailing address:
  • Phone: 920-663-9008
  • Fax: 920-684-1439

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110002238
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: