Provider Demographics
NPI:1326153990
Name:CHARUGUNDLA, KANTI (PA-C)
Entity Type:Individual
Prefix:MS
First Name:KANTI
Middle Name:
Last Name:CHARUGUNDLA
Suffix:
Gender:F
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 1:2740 S BRISTOL ST
Mailing Address - Street 2:SUITE 208
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92704-6209
Mailing Address - Country:US
Mailing Address - Phone:714-979-5734
Mailing Address - Fax:714-979-5781
Practice Address - Street 1:2740 S BRISTOL ST
Practice Address - Street 2:SUITE 208
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92704-6209
Practice Address - Country:US
Practice Address - Phone:714-979-5734
Practice Address - Fax:714-979-5781
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2013-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA18429363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA18429Medicaid
CAWPA18429AMedicare PIN
CAPA18429Medicaid