Basic Information
| Provider Information | |||||||||
| NPI: | 1417320920 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | POTTUKALAM | ||||||||
| FirstName: | RUBY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1648 HUNTINGDON PIKE | ||||||||
| Address2: | MEDICAL STAFF OFFICE FIRST FLOOR | ||||||||
| City: | MEADOWBROOK | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190468001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2159383450 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1648 HUNTINGDON PIKE | ||||||||
| Address2: | |||||||||
| City: | MEADOWBROOK | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190468001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2159382100 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/05/2015 | ||||||||
| LastUpdateDate: | 09/25/2017 | ||||||||
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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 | 363AM0700X | OA003584 | PA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363AM0700X | MA057714 | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.