Provider Demographics
NPI:1144771866
Name:RAYTHATHA, JATAN (PA-C)
Entity Type:Individual
Prefix:
First Name:JATAN
Middle Name:
Last Name:RAYTHATHA
Suffix:
Gender:M
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 1:742 S GOVERNORS AVE
Mailing Address - Street 2:SUITE 3
Mailing Address - City:DOVER
Mailing Address - State:DE
Mailing Address - Zip Code:19904-4111
Mailing Address - Country:US
Mailing Address - Phone:302-678-5008
Mailing Address - Fax:302-678-5505
Practice Address - Street 1:742 S GOVERNORS AVE
Practice Address - Street 2:SUITE 3
Practice Address - City:DOVER
Practice Address - State:DE
Practice Address - Zip Code:19904-4111
Practice Address - Country:US
Practice Address - Phone:302-678-5008
Practice Address - Fax:302-678-5505
Is Sole Proprietor?:No
Enumeration Date:2016-10-18
Last Update Date:2017-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC5-0001132363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical