Provider Demographics
NPI:1871671875
Name:CHIANFAGNA, JEFF (PA)
Entity Type:Individual
Prefix:
First Name:JEFF
Middle Name:
Last Name:CHIANFAGNA
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 1:7035 113TH ST
Mailing Address - Street 2:
Mailing Address - City:FOREST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11375-4651
Mailing Address - Country:US
Mailing Address - Phone:718-990-4648
Mailing Address - Fax:718-990-4414
Practice Address - Street 1:7035 113TH ST
Practice Address - Street 2:
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-4651
Practice Address - Country:US
Practice Address - Phone:718-990-4648
Practice Address - Fax:718-990-4414
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009841363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ27101Medicare UPIN
NY0076SNMedicare ID - Type Unspecified