Provider Demographics
NPI:1942626155
Name:CHACON, ISMARY (PA-C)
Entity Type:Individual
Prefix:
First Name:ISMARY
Middle Name:
Last Name:CHACON
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 1:1558 NW 159TH AVE
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33028-1696
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:301 NE 167TH ST
Practice Address - Street 2:
Practice Address - City:N MIAMI BEACH
Practice Address - State:FL
Practice Address - Zip Code:33162-2304
Practice Address - Country:US
Practice Address - Phone:305-940-0522
Practice Address - Fax:305-653-1138
Is Sole Proprietor?:No
Enumeration Date:2014-03-12
Last Update Date:2014-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9107555363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical