Basic Information
| Provider Information | |||||||||
| NPI: | 1306251780 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GEORGE | ||||||||
| FirstName: | ANU | ||||||||
| MiddleName: | SKARIA | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PAC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CHETTEDATHU | ||||||||
| OtherFirstName: | ANU | ||||||||
| OtherMiddleName: | SKARIA | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PAC | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1335 GERONIMO DR | ||||||||
| Address2: | |||||||||
| City: | EL PASO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 799251836 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9155912704 | ||||||||
| FaxNumber: | 9152250413 | ||||||||
| Practice Location | |||||||||
| Address1: | 6501 N MESA ST | ||||||||
| Address2: | SUITE A | ||||||||
| City: | EL PASO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 799124435 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9155912704 | ||||||||
| FaxNumber: | 9152250413 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/24/2014 | ||||||||
| LastUpdateDate: | 04/04/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 341901201 | 05 | TX | MEDICAID |