Provider Demographics
NPI:1104817568
Name:CHANTAL, KAMAL A (PA-C)
Entity type:Individual
Prefix:
First Name:KAMAL
Middle Name:A
Last Name:CHANTAL
Suffix:
Gender:M
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 1:801 YORK ST
Mailing Address - Street 2:
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54220-4630
Mailing Address - Country:US
Mailing Address - Phone:920-663-9008
Mailing Address - Fax:920-684-1439
Practice Address - Street 1:101 CANDLEWOOD CT
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24502-2654
Practice Address - Country:US
Practice Address - Phone:434-363-4190
Practice Address - Fax:434-363-4191
Is Sole Proprietor?:No
Enumeration Date:2005-11-03
Last Update Date:2024-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110002238363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1104817568Medicaid
00968OT88Medicare PIN
Q22684Medicare UPIN
VA1104817568Medicaid
VVJ546AMedicare PIN
VA1104817568Medicaid