Provider Demographics
NPI:1487222188
Name:CHANTHASOTO, MALYSSA EMILY (PA-C)
Entity Type:Individual
Prefix:
First Name:MALYSSA
Middle Name:EMILY
Last Name:CHANTHASOTO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1111 CROMWELL AVE STE 404
Mailing Address - Street 2:
Mailing Address - City:ROCKY HILL
Mailing Address - State:CT
Mailing Address - Zip Code:06067-3455
Mailing Address - Country:US
Mailing Address - Phone:551-427-7163
Mailing Address - Fax:
Practice Address - Street 1:1111 CROMWELL AVE STE 404
Practice Address - Street 2:
Practice Address - City:ROCKY HILL
Practice Address - State:CT
Practice Address - Zip Code:06067-3455
Practice Address - Country:US
Practice Address - Phone:860-525-4469
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-17
Last Update Date:2021-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT5241363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty