Provider Demographics
NPI:1629051826
Name:ARIYAWANSA, PADMA M (MD)
Entity Type:Individual
Prefix:
First Name:PADMA
Middle Name:M
Last Name:ARIYAWANSA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 15645
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89114-5645
Mailing Address - Country:US
Mailing Address - Phone:702-560-2900
Mailing Address - Fax:702-560-2928
Practice Address - Street 1:4475 S EASTERN AVE
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89119-7826
Practice Address - Country:US
Practice Address - Phone:702-669-5840
Practice Address - Fax:702-650-5729
Is Sole Proprietor?:No
Enumeration Date:2005-11-22
Last Update Date:2014-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00030248208000000X
IDM6126208000000X
NV15235208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8143166Medicaid
NV1629051826Medicaid
WA8143166Medicaid
NVV108109Medicare PIN
WAF42329Medicare UPIN