Provider Demographics
NPI:1619573631
Name:CHANDEBAL, JASON AVINASH (PA)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:AVINASH
Last Name:CHANDEBAL
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26701 HILLSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:FLORAL PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11004-1743
Mailing Address - Country:US
Mailing Address - Phone:718-343-7790
Mailing Address - Fax:
Practice Address - Street 1:26701 HILLSIDE AVE
Practice Address - Street 2:
Practice Address - City:GLEN OAKS
Practice Address - State:NY
Practice Address - Zip Code:11004-1743
Practice Address - Country:US
Practice Address - Phone:718-343-7790
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-06
Last Update Date:2021-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY026517363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty