Provider Demographics
NPI:1528013497
Name:CHANTAL, ALEXIS R (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:ALEXIS
Middle Name:R
Last Name:CHANTAL
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 1:8243 CHARLEMONT RD
Mailing Address - Street 2:
Mailing Address - City:GOODE
Mailing Address - State:VA
Mailing Address - Zip Code:24556-3112
Mailing Address - Country:US
Mailing Address - Phone:814-574-1582
Mailing Address - Fax:
Practice Address - Street 1:876A E MAIN ST
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:VA
Practice Address - Zip Code:24523-2904
Practice Address - Country:US
Practice Address - Phone:434-947-5321
Practice Address - Fax:434-947-5324
Is Sole Proprietor?:No
Enumeration Date:2006-05-22
Last Update Date:2022-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110002287363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA541667390OtherTAX ID
VAQ71332Medicare UPIN