Provider Demographics
NPI:1578874178
Name:TRAMBADIA, ANJALI LATISHA (PA)
Entity Type:Individual
Prefix:
First Name:ANJALI
Middle Name:LATISHA
Last Name:TRAMBADIA
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:ANJALI
Other - Middle Name:LATISHA
Other - Last Name:GANDHI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:PO BOX 116116
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30368-6116
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:20 FRANCIS WAY
Practice Address - Street 2:SUITE 101
Practice Address - City:SHARPSBURG
Practice Address - State:GA
Practice Address - Zip Code:30277-3589
Practice Address - Country:US
Practice Address - Phone:770-253-0611
Practice Address - Fax:770-502-0521
Is Sole Proprietor?:No
Enumeration Date:2010-06-29
Last Update Date:2022-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA005835363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA102098920AMedicaid
GA202I976096Medicare PIN