Provider Demographics
NPI:1265521942
Name:ATHRI, RANGANATH (NP)
Entity type:Individual
Prefix:
First Name:RANGANATH
Middle Name:
Last Name:ATHRI
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:RANGANATH
Other - Middle Name:
Other - Last Name:KRISHNAMURTHY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:618 N MAIN ST
Mailing Address - Street 2:STE A
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46545-6620
Mailing Address - Country:US
Mailing Address - Phone:517-580-0575
Mailing Address - Fax:
Practice Address - Street 1:2109 HAMILTON RD STE 217
Practice Address - Street 2:
Practice Address - City:OKEMOS
Practice Address - State:MI
Practice Address - Zip Code:48864-1700
Practice Address - Country:US
Practice Address - Phone:517-580-0575
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2021-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704204350363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4789569Medicaid
MI4789569Medicaid