Basic Information
Provider Information | |||||||||
NPI: | 1437144953 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CHAPMAN | ||||||||
FirstName: | RICHARD | ||||||||
MiddleName: | KENT | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 4059 | ||||||||
Address2: |   | ||||||||
City: | WAYNE | ||||||||
State: | NJ | ||||||||
PostalCode: | 074744059 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9738268291 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 4215 EDGEWATER DR | ||||||||
Address2: |   | ||||||||
City: | ORLANDO | ||||||||
State: | FL | ||||||||
PostalCode: | 328042206 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4075392000 | ||||||||
FaxNumber: | 4073980050 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/12/2005 | ||||||||
LastUpdateDate: | 03/11/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/11/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | PA2630 | FL | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
ID | Type | State | Issuer | Description | 290122600 | 05 | FL |   | MEDICAID | HF826A | 01 | FL | MEDICARE GROUP PTAN | OTHER | P01393508 | 01 | FL | RR MEDICARE | OTHER |