Provider Demographics
NPI:1750432142
Name:BALKISHUN, VIDYA NANDINI (PA-C)
Entity type:Individual
Prefix:
First Name:VIDYA
Middle Name:NANDINI
Last Name:BALKISHUN
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 1:1915 WHITE AVE
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37916-2300
Mailing Address - Country:US
Mailing Address - Phone:865-331-1720
Mailing Address - Fax:
Practice Address - Street 1:18947 JOHN J WILLIAMS HWY UNIT 101
Practice Address - Street 2:
Practice Address - City:REHOBOTH BEACH
Practice Address - State:DE
Practice Address - Zip Code:19971-4480
Practice Address - Country:US
Practice Address - Phone:302-645-3770
Practice Address - Fax:302-645-5718
Is Sole Proprietor?:No
Enumeration Date:2007-01-15
Last Update Date:2024-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA051675363AM0700X
TN4813363AM0700X
DEC5-0012102363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ070965Medicaid