Provider Demographics
NPI:1962156760
Name:SURYADEVARA, SRIYANSHI (PA)
Entity type:Individual
Prefix:MR
First Name:SRIYANSHI
Middle Name:
Last Name:SURYADEVARA
Suffix:
Gender:
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7412011
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60674-2011
Mailing Address - Country:US
Mailing Address - Phone:314-362-7200
Mailing Address - Fax:314-747-4189
Practice Address - Street 1:510 S KINGSHIGHWAY BLVD
Practice Address - Street 2:DEPT RADIOLOGY
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-1016
Practice Address - Country:US
Practice Address - Phone:314-362-7200
Practice Address - Fax:314-747-4189
Is Sole Proprietor?:No
Enumeration Date:2022-02-09
Last Update Date:2025-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2022039245363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO220115727Medicaid