Provider Demographics
NPI:1417947631
Name:KANTHARAJ, MARY SUJANA (RPA-C)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:SUJANA
Last Name:KANTHARAJ
Suffix:
Gender:F
Credentials:RPA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 RIVERSIDE DR
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:NY
Mailing Address - Zip Code:13790-2742
Mailing Address - Country:US
Mailing Address - Phone:607-770-9050
Mailing Address - Fax:607-770-9091
Practice Address - Street 1:15 RIVERSIDE DR
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:NY
Practice Address - Zip Code:13790-2742
Practice Address - Country:US
Practice Address - Phone:607-770-9050
Practice Address - Fax:607-770-9091
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-27
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009664363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01283132Medicaid
NY01283132Medicaid
NYS34908Medicare UPIN