Provider Demographics
NPI:1154658664
Name:RAVISHANKARA, AMELIA SITA
Entity Type:Individual
Prefix:
First Name:AMELIA
Middle Name:SITA
Last Name:RAVISHANKARA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7931 W 55TH AVE
Mailing Address - Street 2:APT 202
Mailing Address - City:ARVADA
Mailing Address - State:CO
Mailing Address - Zip Code:80002-3704
Mailing Address - Country:US
Mailing Address - Phone:720-352-0892
Mailing Address - Fax:
Practice Address - Street 1:580 MOHAWK DRIVE
Practice Address - Street 2:BASELINE MEDICAL OFFICE
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80302
Practice Address - Country:US
Practice Address - Phone:303-614-1400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-05
Last Update Date:2009-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist