Provider Demographics
NPI:1396147468
Name:CHENOT, ANTHONY TREVOR (SURFACE IDC)
Entity type:Individual
Prefix:
First Name:ANTHONY
Middle Name:TREVOR
Last Name:CHENOT
Suffix:
Gender:M
Credentials:SURFACE IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8236 STATION VILLAGE LN
Mailing Address - Street 2:APARTMENT 1809
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92108-5560
Mailing Address - Country:US
Mailing Address - Phone:702-596-1244
Mailing Address - Fax:
Practice Address - Street 1:8236 STATION VILLAGE LN
Practice Address - Street 2:APARTMENT 1809
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-5560
Practice Address - Country:US
Practice Address - Phone:702-596-1244
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-20
Last Update Date:2014-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1710I1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman