Provider Demographics
NPI:1780613414
Name:CHAKA, TED A (PA)
Entity type:Individual
Prefix:
First Name:TED
Middle Name:A
Last Name:CHAKA
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 1:2074 ANTILLEY RD
Mailing Address - Street 2:
Mailing Address - City:ABILENE
Mailing Address - State:TX
Mailing Address - Zip Code:79606-5209
Mailing Address - Country:US
Mailing Address - Phone:253-698-3865
Mailing Address - Fax:325-793-1295
Practice Address - Street 1:2074 ANTILLEY RD
Practice Address - Street 2:
Practice Address - City:ABILENE
Practice Address - State:TX
Practice Address - Zip Code:79606-5209
Practice Address - Country:US
Practice Address - Phone:325-698-3865
Practice Address - Fax:325-793-1295
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2020-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA04129363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXPA04129OtherTX STATE PA LICENSE
TX8F3222Medicare PIN
TXQ19433Medicare UPIN