Provider Demographics
NPI:1972078673
Name:PERERA, SANJAYA P
Entity Type:Individual
Prefix:
First Name:SANJAYA
Middle Name:P
Last Name:PERERA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:649 S CHERRYWOOD CIR
Mailing Address - Street 2:
Mailing Address - City:ANDOVER
Mailing Address - State:KS
Mailing Address - Zip Code:67002-8948
Mailing Address - Country:US
Mailing Address - Phone:316-708-1950
Mailing Address - Fax:
Practice Address - Street 1:649 S CHERRYWOOD CIR
Practice Address - Street 2:
Practice Address - City:ANDOVER
Practice Address - State:KS
Practice Address - Zip Code:67002-8948
Practice Address - Country:US
Practice Address - Phone:316-708-1950
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-09
Last Update Date:2018-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSK02000264172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver