Provider Demographics
NPI:1225684244
Name:KUMAR, KRISHAN RAJ
Entity Type:Individual
Prefix:
First Name:KRISHAN
Middle Name:RAJ
Last Name:KUMAR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 BUCKEYE COVE RD
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:NC
Mailing Address - Zip Code:28716-4511
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:55 BUCKEYE COVE RD
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:NC
Practice Address - Zip Code:28716-4511
Practice Address - Country:US
Practice Address - Phone:828-648-0282
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-15
Last Update Date:2022-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-10651363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
000923150OtherGWU STUDENT ID