Provider Demographics
NPI:1760849939
Name:KEYPOUR, CHANTAL KAMILA (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:
First Name:CHANTAL
Middle Name:KAMILA
Last Name:KEYPOUR
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 FRANKLIN AVE STE UL3A&B
Mailing Address - Street 2:
Mailing Address - City:GARDEN CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11530-1886
Mailing Address - Country:US
Mailing Address - Phone:516-747-8900
Mailing Address - Fax:
Practice Address - Street 1:1300 FRANKLIN AVE STE UL3A&B
Practice Address - Street 2:
Practice Address - City:GARDEN CITY
Practice Address - State:NY
Practice Address - Zip Code:11530-1886
Practice Address - Country:US
Practice Address - Phone:516-747-8900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-19
Last Update Date:2021-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY019380363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant