Provider Demographics
NPI:1205974045
Name:THIBODAUX, CHANDLER N (PA)
Entity type:Individual
Prefix:
First Name:CHANDLER
Middle Name:N
Last Name:THIBODAUX
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:CHANDLER
Other - Middle Name:N
Other - Last Name:THIBODAUX
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA
Mailing Address - Street 1:413 EAGLE DR
Mailing Address - Street 2:
Mailing Address - City:BEDFORD
Mailing Address - State:TX
Mailing Address - Zip Code:76021-3219
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1307 8TH AVE STE 505
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-4143
Practice Address - Country:US
Practice Address - Phone:817-927-2332
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-02
Last Update Date:2014-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX01790363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant