Provider Demographics
NPI:1033405154
Name:AMMANNAGARI, NISCHALA (MD)
Entity Type:Individual
Prefix:DR
First Name:NISCHALA
Middle Name:
Last Name:AMMANNAGARI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:449 ROUTE 146
Mailing Address - Street 2:STE 101
Mailing Address - City:HALFMOON
Mailing Address - State:NY
Mailing Address - Zip Code:12065-3239
Mailing Address - Country:US
Mailing Address - Phone:518-373-3924
Mailing Address - Fax:518-373-3808
Practice Address - Street 1:400 PATROON CREEK BLVD STE 1
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12206-5014
Practice Address - Country:US
Practice Address - Phone:518-489-0044
Practice Address - Fax:518-489-3591
Is Sole Proprietor?:No
Enumeration Date:2011-06-27
Last Update Date:2019-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY287081207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04891250Medicaid