Provider Demographics
NPI:1588902316
Name:MOTHE, SUMANTH VAMSHIDHAR (PA-C, MMS)
Entity type:Individual
Prefix:MR
First Name:SUMANTH
Middle Name:VAMSHIDHAR
Last Name:MOTHE
Suffix:
Gender:M
Credentials:PA-C, MMS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Mailing Address - Street 1:8 CHARLES PLZ APT 1307
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21201-4221
Mailing Address - Country:US
Mailing Address - Phone:443-983-3210
Mailing Address - Fax:
Practice Address - Street 1:9710 BRIMHALL RD
Practice Address - Street 2:
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93312-2779
Practice Address - Country:US
Practice Address - Phone:661-829-6747
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-29
Last Update Date:2021-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA22801363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant