Provider Demographics
NPI:1154737492
Name:CHANEY, IZOLA MARY (PA-C)
Entity type:Individual
Prefix:
First Name:IZOLA
Middle Name:MARY
Last Name:CHANEY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:IZOLA
Other - Middle Name:MARY
Other - Last Name:PHILLIPS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:21830 CACTUS AVE STE 302
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92518-3010
Mailing Address - Country:US
Mailing Address - Phone:951-653-5291
Mailing Address - Fax:
Practice Address - Street 1:21830 CACTUS AVE STE 302
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92518-3010
Practice Address - Country:US
Practice Address - Phone:951-653-5291
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-08
Last Update Date:2022-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA22885363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant