Provider Demographics
NPI:1487938270
Name:CHESNUT, CANDACE D (PA-C)
Entity type:Individual
Prefix:MRS
First Name:CANDACE
Middle Name:D
Last Name:CHESNUT
Suffix:
Gender:F
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 1:209 W 7TH ST
Mailing Address - Street 2:
Mailing Address - City:COFFEYVILLE
Mailing Address - State:KS
Mailing Address - Zip Code:67337-4954
Mailing Address - Country:US
Mailing Address - Phone:620-251-1100
Mailing Address - Fax:
Practice Address - Street 1:1102 W 32ND ST
Practice Address - Street 2:
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64804-3503
Practice Address - Country:US
Practice Address - Phone:417-347-1111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-28
Last Update Date:2021-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2014030133363A00000X
KS1501488363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant