Provider Demographics
NPI:1457827651
Name:CHALLA, SPOORTHY (PA-C)
Entity Type:Individual
Prefix:
First Name:SPOORTHY
Middle Name:
Last Name:CHALLA
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 1:207 N BROAD ST FL 3
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-1500
Mailing Address - Country:US
Mailing Address - Phone:215-361-5020
Mailing Address - Fax:215-362-1195
Practice Address - Street 1:125 MEDICAL CAMPUS DR STE 101
Practice Address - Street 2:
Practice Address - City:LANSDALE
Practice Address - State:PA
Practice Address - Zip Code:19446-7205
Practice Address - Country:US
Practice Address - Phone:215-361-5020
Practice Address - Fax:215-362-1195
Is Sole Proprietor?:No
Enumeration Date:2018-10-16
Last Update Date:2023-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA060254363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty