Basic Information
Provider Information | |||||||||
NPI: | 1912013954 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LATHA | ||||||||
FirstName: | SWARNA | ||||||||
MiddleName: | ERRAMREDDI | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1852 N MASTICK WAY | ||||||||
Address2: |   | ||||||||
City: | NOGALES | ||||||||
State: | AZ | ||||||||
PostalCode: | 856211063 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5207612128 | ||||||||
FaxNumber: | 5202811112 | ||||||||
Practice Location | |||||||||
Address1: | 675 WATER ST | ||||||||
Address2: |   | ||||||||
City: | EXCELSIOR | ||||||||
State: | MN | ||||||||
PostalCode: | 553313063 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9524744167 | ||||||||
FaxNumber: | 9524745700 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/22/2006 | ||||||||
LastUpdateDate: | 12/13/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 12/13/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 36343 | MN | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 100537 | 01 | MN | UCARE | OTHER | 566K6LA | 01 | MN | HEALTHPARTNERS | OTHER | 58784 | 01 | MN | ARAZ | OTHER | 566K61A | 01 | MN | BLUE CROSS | OTHER | O85231700 | 05 | MN |   | MEDICAID | 012552 | 01 | MN | MEDICA | OTHER |