Provider Demographics
NPI:1306396700
Name:RAJYAGURU, PRUTHA R (PA-C)
Entity type:Individual
Prefix:
First Name:PRUTHA
Middle Name:R
Last Name:RAJYAGURU
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:PRUTHA
Other - Middle Name:
Other - Last Name:PANCHAL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:12255 S 80TH AVE STE 203
Mailing Address - Street 2:
Mailing Address - City:PALOS HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60463-1284
Mailing Address - Country:US
Mailing Address - Phone:708-827-2021
Mailing Address - Fax:708-827-2241
Practice Address - Street 1:12255 S 80TH AVE STE 203
Practice Address - Street 2:
Practice Address - City:PALOS HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60463-1284
Practice Address - Country:US
Practice Address - Phone:708-827-2021
Practice Address - Fax:708-827-2241
Is Sole Proprietor?:No
Enumeration Date:2016-10-10
Last Update Date:2025-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA53876363A00000X
IN10004020A363A00000X
IL085008524363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN068010915OtherMEDICARE PTAN
IN300077922Medicaid
IL085008524OtherSTATE LICENSE