Provider Demographics
NPI:1992125116
Name:TUMMALA, PADMAVATHI (PA-C)
Entity type:Individual
Prefix:
First Name:PADMAVATHI
Middle Name:
Last Name:TUMMALA
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 1:11109 PARKVIEW PLAZA DR # 117
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2708 GUILFORD ST
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:IN
Practice Address - Zip Code:46750
Practice Address - Country:US
Practice Address - Phone:260-355-3900
Practice Address - Fax:260-355-3079
Is Sole Proprietor?:No
Enumeration Date:2014-04-27
Last Update Date:2022-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10001516A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN10001516AMedicaid
IN10001516AMedicare Oscar/Certification
10001516AMedicare UPIN
IN10001516AMedicaid