Provider Demographics
NPI:1982435129
Name:CHIVUKULA, VASUDHA (PA-C)
Entity type:Individual
Prefix:
First Name:VASUDHA
Middle Name:
Last Name:CHIVUKULA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1097B N CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:HAZLE TOWNSHIP
Mailing Address - State:PA
Mailing Address - Zip Code:18202-1465
Mailing Address - Country:US
Mailing Address - Phone:272-639-5650
Mailing Address - Fax:242-639-5651
Practice Address - Street 1:1097B N CHURCH ST
Practice Address - Street 2:
Practice Address - City:HAZLE TOWNSHIP
Practice Address - State:PA
Practice Address - Zip Code:18202-1465
Practice Address - Country:US
Practice Address - Phone:272-639-5650
Practice Address - Fax:242-639-5651
Is Sole Proprietor?:No
Enumeration Date:2024-08-09
Last Update Date:2025-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA065828363AM0700X
PAOA007154363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical