Provider Demographics
NPI:1639391683
Name:PANGANAMALA, JOYCE RAO (PA)
Entity Type:Individual
Prefix:
First Name:JOYCE
Middle Name:RAO
Last Name:PANGANAMALA
Suffix:
Gender:F
Credentials:PA
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 637676
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-7676
Mailing Address - Country:US
Mailing Address - Phone:513-853-4749
Mailing Address - Fax:513-853-4743
Practice Address - Street 1:11029 MONTGOMERY RD
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45249-2306
Practice Address - Country:US
Practice Address - Phone:513-891-2211
Practice Address - Fax:513-891-2218
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2021-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.004010RX363A00000X
OH50.004010363AM0700X
MAAP2134207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0462231Medicaid
OH2565399Medicaid