Basic Information
| Provider Information | |||||||||
| NPI: | 1598756199 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHANDLER | ||||||||
| FirstName: | PAUL | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2142 N COVE BLVD | ||||||||
| Address2: | |||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436063895 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192915318 | ||||||||
| FaxNumber: | 4192916430 | ||||||||
| Practice Location | |||||||||
| Address1: | 2150 W CENTRAL AVE | ||||||||
| Address2: | |||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436063834 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192912192 | ||||||||
| FaxNumber: | 4194793297 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/02/2005 | ||||||||
| LastUpdateDate: | 04/05/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 50001176 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 0070480 | 05 | OH | MEDICAID |