Provider Demographics
NPI:1508909045
Name:CHACKO, SUMY (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:SUMY
Middle Name:
Last Name:CHACKO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MRS
Other - First Name:SUMY
Other - Middle Name:
Other - Last Name:CHACKO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:2429 EPSTEIN CT
Mailing Address - Street 2:
Mailing Address - City:BROOKEVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20833-3263
Mailing Address - Country:US
Mailing Address - Phone:516-313-5928
Mailing Address - Fax:
Practice Address - Street 1:18101 PRINCE PHILIP DR
Practice Address - Street 2:
Practice Address - City:OLNEY
Practice Address - State:MD
Practice Address - Zip Code:20832-1514
Practice Address - Country:US
Practice Address - Phone:301-774-4105
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-15
Last Update Date:2010-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011290363A00000X
MDC0004157363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant