Provider Demographics
NPI:1184098246
Name:DITOMMASO, CHAUNTEL JOYCE (PA)
Entity type:Individual
Prefix:MRS
First Name:CHAUNTEL
Middle Name:JOYCE
Last Name:DITOMMASO
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MS
Other - First Name:CHAUNTEL
Other - Middle Name:JOYCE
Other - Last Name:SHANNON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1060 BRAYDAN
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:TX
Mailing Address - Zip Code:75462-5902
Mailing Address - Country:US
Mailing Address - Phone:405-795-4622
Mailing Address - Fax:
Practice Address - Street 1:1201 E JACKSON ST
Practice Address - Street 2:
Practice Address - City:HUGO
Practice Address - State:OK
Practice Address - Zip Code:74743-4229
Practice Address - Country:US
Practice Address - Phone:580-326-6423
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-30
Last Update Date:2015-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant