Provider Demographics
NPI:1023340379
Name:AGRAWAL, ANJALI (PA)
Entity type:Individual
Prefix:
First Name:ANJALI
Middle Name:
Last Name:AGRAWAL
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 1:3010 BEARD RD
Mailing Address - Street 2:
Mailing Address - City:NAPA
Mailing Address - State:CA
Mailing Address - Zip Code:94558-3442
Mailing Address - Country:US
Mailing Address - Phone:707-255-8825
Mailing Address - Fax:707-252-9325
Practice Address - Street 1:2531 N CALIFORNIA ST
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95204-5501
Practice Address - Country:US
Practice Address - Phone:209-464-7738
Practice Address - Fax:209-464-5142
Is Sole Proprietor?:No
Enumeration Date:2010-02-10
Last Update Date:2014-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA 20756363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1023340379Medicare PIN