Provider Demographics
NPI:1003992686
Name:SURENDERANATH, NISHA K (MD)
Entity Type:Individual
Prefix:DR
First Name:NISHA
Middle Name:K
Last Name:SURENDERANATH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:605 EMANCIPATION HWY STE 101
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22401-8403
Mailing Address - Country:US
Mailing Address - Phone:423-463-4713
Mailing Address - Fax:
Practice Address - Street 1:605 EMANCIPATION HWY
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22401-8403
Practice Address - Country:US
Practice Address - Phone:540-310-0117
Practice Address - Fax:540-310-4736
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-27
Last Update Date:2022-04-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TN422832080P0202X
VA01012728562080P0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3000900Medicaid