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General NPI Number Information
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NPI Number | 1174378525
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Entity Type | Organization
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Legal Business Name | CHACON BNK PC
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Dates
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Enumeration Date | 04/19/2024
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Last Update Date | 09/19/2024
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Provider Practice Location Address
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Address Line | 2203 PLAZA DR STE 110
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City | ROCKLIN
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State | CA
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Zip | 95765-4427
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Country | US
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Telephone | 916-938-2531
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Fax |
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Provider Business Mailing Address
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Address Line | 2203 PLAZA DR STE 110
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City | ROCKLIN
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State | CA
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Zip | 95765-4427
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Country | US
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Telephone | 916-938-2531
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Fax |
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Authorized Official
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Title or Position | AUTHORIZED OFFICIAL
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Name | SIDDHARTH SHAH
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Credential |
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Telephone | 770-864-2620
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 207N00000X
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Taxonomy Name | Dermatology Physician
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License Number |
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License Number State |
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