Provider Demographics
NPI:1457443418
Name:LASSAK, CHANTELLE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:CHANTELLE
Middle Name:
Last Name:LASSAK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:CHANTELLE
Other - Middle Name:
Other - Last Name:BOTKIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6285 S HIGLEY RD
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85298-4262
Mailing Address - Country:US
Mailing Address - Phone:480-460-4949
Mailing Address - Fax:480-460-5858
Practice Address - Street 1:6285 S HIGLEY RD
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85298
Practice Address - Country:US
Practice Address - Phone:480-460-4949
Practice Address - Fax:480-490-5858
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2021-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3064363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant