Provider Demographics
NPI:1861498768
Name:CHAMBELLAN, KENDALL YAZZIE REDHORSE (PA)
Entity Type:Individual
Prefix:MR
First Name:KENDALL
Middle Name:YAZZIE REDHORSE
Last Name:CHAMBELLAN
Suffix:
Gender:M
Credentials:PA
Other - Prefix:MR
Other - First Name:KEN
Other - Middle Name:
Other - Last Name:CHAMBELLAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA
Mailing Address - Street 1:PO BOX 846098
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-6098
Mailing Address - Country:US
Mailing Address - Phone:903-324-6400
Mailing Address - Fax:
Practice Address - Street 1:811 S WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:MARSHALL
Practice Address - State:TX
Practice Address - Zip Code:75670
Practice Address - Country:US
Practice Address - Phone:903-315-1488
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-24
Last Update Date:2024-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA 01658363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX794785OtherMEDICARE
TXP02237142OtherMEDICARE RAIL ROAD
TX192935811Medicaid