MEDICARE: CHANDLER N THIBODAUX P.A

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	01790	TX

General Provider Information

NPI Number	:	1205974045
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHANDLER N THIBODAUX P.A

Provider Business Mailing Address
First Line	:	413 EAGLE DR
Second Line	:
City	:	BEDFORD
State	:	TX
Zip	:	76021-3219
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1307 8TH AVE STE 505
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76104-4143
Country	:	US
Telephone Number	:	817-927-2332
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/02/2007
Last Update Date	:	06/11/2014

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