Provider Demographics
NPI:1942065420
Name:CHAVES, JUSTIN MIGUEL
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:MIGUEL
Last Name:CHAVES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7777 FOREST LANE SUITE B-412
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75230
Mailing Address - Country:US
Mailing Address - Phone:972-566-5560
Mailing Address - Fax:
Practice Address - Street 1:7777 FOREST LN STE B412
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75230-6824
Practice Address - Country:US
Practice Address - Phone:972-566-5560
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-14
Last Update Date:2024-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA17967363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant