Basic Information
| Provider Information | |||||||||
| NPI: | 1093264400 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RAVAL | ||||||||
| FirstName: | CHANDNI | ||||||||
| MiddleName: | VINAY | ||||||||
| NamePrefix: | |||||||||
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| Credential: | P.A. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KAPADIA | ||||||||
| OtherFirstName: | CHANDNI | ||||||||
| OtherMiddleName: | VINAY | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2196 FENTON PKWY | ||||||||
| Address2: | APARTMENT 217 | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921084770 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6235700595 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5333 MISSION CENTER RD | ||||||||
| Address2: | SUITE #100 | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921081302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6192953355 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/26/2016 | ||||||||
| LastUpdateDate: | 09/26/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 53626 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.