Provider Demographics
NPI:1033236260
Name:KRISHNAN, SIVA SANKAR (PTA)
Entity Type:Individual
Prefix:MR
First Name:SIVA
Middle Name:SANKAR
Last Name:KRISHNAN
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:903 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:YADKINVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27055-7807
Mailing Address - Country:US
Mailing Address - Phone:336-679-8863
Mailing Address - Fax:
Practice Address - Street 1:903 W MAIN ST
Practice Address - Street 2:
Practice Address - City:YADKINVILLE
Practice Address - State:NC
Practice Address - Zip Code:27055-7807
Practice Address - Country:US
Practice Address - Phone:336-679-8863
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-23
Last Update Date:2011-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3345225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant