Provider Demographics
NPI:1669003745
Name:CHACKO, MYSTY (PA-C)
Entity type:Individual
Prefix:
First Name:MYSTY
Middle Name:
Last Name:CHACKO
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 1:1 FEDERAL ST STE 200
Mailing Address - Street 2:
Mailing Address - City:CAMDEN
Mailing Address - State:NJ
Mailing Address - Zip Code:08103-1088
Mailing Address - Country:US
Mailing Address - Phone:848-288-6935
Mailing Address - Fax:732-790-0107
Practice Address - Street 1:400 W ROUTE 38
Practice Address - Street 2:
Practice Address - City:MOORESTOWN
Practice Address - State:NJ
Practice Address - Zip Code:08057-3219
Practice Address - Country:US
Practice Address - Phone:856-270-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-28
Last Update Date:2024-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA061392207RG0100X
NJ25MP00866300363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology