Provider Demographics
NPI:1720389513
Name:FATEHCHAND, PRAMODA (PA C)
Entity Type:Individual
Prefix:
First Name:PRAMODA
Middle Name:
Last Name:FATEHCHAND
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:PO BOX 228
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:OH
Mailing Address - Zip Code:43138-0228
Mailing Address - Country:US
Mailing Address - Phone:740-380-8410
Mailing Address - Fax:740-385-9197
Practice Address - Street 1:601 STATE ROUTE 664 N
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:OH
Practice Address - Zip Code:43138-8541
Practice Address - Country:US
Practice Address - Phone:740-380-8410
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-09
Last Update Date:2020-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVPPA01520363A00000X
OH003529363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0076776Medicaid
OH0076776Medicaid