Provider Demographics
NPI:1427509611
Name:CHANNA, SUPINDER (NP)
Entity type:Individual
Prefix:
First Name:SUPINDER
Middle Name:
Last Name:CHANNA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:151 HAROLD FLEMING CT
Mailing Address - Street 2:
Mailing Address - City:SPARTANBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29303-4225
Mailing Address - Country:US
Mailing Address - Phone:864-573-6320
Mailing Address - Fax:864-208-0352
Practice Address - Street 1:151 HAROLD FLEMING CT
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29303-4225
Practice Address - Country:US
Practice Address - Phone:864-573-6320
Practice Address - Fax:864-208-0352
Is Sole Proprietor?:No
Enumeration Date:2016-10-22
Last Update Date:2021-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC20433207RP1001X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP3212Medicaid
SC7034Medicare PIN