Basic Information
| Provider Information | |||||||||
| NPI: | 1144630930 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SANGWAN | ||||||||
| FirstName: | PRAVESH | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1701 INNOVATION DR | ||||||||
| Address2: | |||||||||
| City: | YORK | ||||||||
| State: | PA | ||||||||
| PostalCode: | 174088815 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1701 INNOVATION DR | ||||||||
| Address2: | |||||||||
| City: | YORK | ||||||||
| State: | PA | ||||||||
| PostalCode: | 174088815 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7178504040 | ||||||||
| FaxNumber: | 7178504144 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/01/2014 | ||||||||
| LastUpdateDate: | 04/09/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080N0001X | 4301112251 | MI | Y | Allopathic & Osteopathic Physicians | Pediatrics | Neonatal-Perinatal Medicine | 208000000X | 4301112251 | MI | N | Allopathic & Osteopathic Physicians | Pediatrics | 2080N0001X | MD471253 | PA | N | Allopathic & Osteopathic Physicians | Pediatrics | Neonatal-Perinatal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 103806612 | 05 | PA | MEDICAID |