Provider Demographics
NPI:1851643670
Name:SURENDRA, KAYLEIGH (PA-C)
Entity Type:Individual
Prefix:
First Name:KAYLEIGH
Middle Name:
Last Name:SURENDRA
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 1:8385 MONTGOMERY RUN RD
Mailing Address - Street 2:APT G
Mailing Address - City:ELLICOTT CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21043-7218
Mailing Address - Country:US
Mailing Address - Phone:443-315-3785
Mailing Address - Fax:
Practice Address - Street 1:6040 SYKESVILLE RD
Practice Address - Street 2:
Practice Address - City:ELDERSBURG
Practice Address - State:MD
Practice Address - Zip Code:21784-6000
Practice Address - Country:US
Practice Address - Phone:410-781-4720
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-03
Last Update Date:2016-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC04829363A00000X
NC0010-04330363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant