Basic Information
| Provider Information | |||||||||
| NPI: | 1477895035 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VENKATARAMAN | ||||||||
| FirstName: | PUSHPALATHA | ||||||||
| MiddleName: | TIRUMALE | ||||||||
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| Credential: | PHYSICIAN ASSISTANT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9220 MENTOR AVE | ||||||||
| Address2: | |||||||||
| City: | MENTOR | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440606412 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4403549924 | ||||||||
| FaxNumber: | 8772429583 | ||||||||
| Practice Location | |||||||||
| Address1: | 801 E WASHINGTON ST | ||||||||
| Address2: | SUITE 150 | ||||||||
| City: | MEDINA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 442563335 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3307221069 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/21/2013 | ||||||||
| LastUpdateDate: | 09/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/21/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 50.003757 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.