Provider Demographics
NPI:1578914842
Name:ASLAN, CHANNDARA THACH (PA-C)
Entity Type:Individual
Prefix:
First Name:CHANNDARA
Middle Name:THACH
Last Name:ASLAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:CHANNDARA
Other - Middle Name:
Other - Last Name:THACH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:450 N 18TH ST APT 640
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19130-4193
Mailing Address - Country:US
Mailing Address - Phone:205-370-5363
Mailing Address - Fax:
Practice Address - Street 1:1 MEDICAL CENTER BLVD
Practice Address - Street 2:
Practice Address - City:CHESTER
Practice Address - State:PA
Practice Address - Zip Code:19013-3902
Practice Address - Country:US
Practice Address - Phone:610-874-5257
Practice Address - Fax:610-874-7241
Is Sole Proprietor?:No
Enumeration Date:2016-06-28
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPA 1153363A00000X
PAMA059668363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant