Provider Demographics
NPI:1740431758
Name:GOGULA, SUJATHA R (PA)
Entity Type:Individual
Prefix:MS
First Name:SUJATHA
Middle Name:R
Last Name:GOGULA
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 1:431 W LIBERTY ST
Mailing Address - Street 2:
Mailing Address - City:WAUCONDA
Mailing Address - State:IL
Mailing Address - Zip Code:60084-2452
Mailing Address - Country:US
Mailing Address - Phone:847-526-2151
Mailing Address - Fax:815-678-4184
Practice Address - Street 1:431 W LIBERTY ST
Practice Address - Street 2:
Practice Address - City:WAUCONDA
Practice Address - State:IL
Practice Address - Zip Code:60084-2452
Practice Address - Country:US
Practice Address - Phone:847-526-2151
Practice Address - Fax:815-678-4184
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-08
Last Update Date:2008-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085003332363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL085003332OtherSTATE LICENSE FROM ILLINOIS