Provider Demographics
NPI:1669003745
Name:CHACKO, MYSTY (PA-C)
Entity Type:Individual
Prefix:
First Name:MYSTY
Middle Name:
Last Name:CHACKO
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 1:132 S 10TH STREET
Mailing Address - Street 2:480 MAIN BUILDING
Mailing Address - City:PHILA
Mailing Address - State:PA
Mailing Address - Zip Code:19107
Mailing Address - Country:US
Mailing Address - Phone:215-955-8900
Mailing Address - Fax:215-955-5245
Practice Address - Street 1:132 S 10TH ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-5244
Practice Address - Country:US
Practice Address - Phone:215-955-8900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-28
Last Update Date:2020-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA061392207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology