Provider Demographics
NPI:1811340391
Name:KOLLI, DIVYA LAKSHMI (PA-C)
Entity type:Individual
Prefix:
First Name:DIVYA
Middle Name:LAKSHMI
Last Name:KOLLI
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:DIVYA
Other - Middle Name:LAKSHMI
Other - Last Name:PANDURANGADU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:935 MARKET ST
Mailing Address - Street 2:
Mailing Address - City:YUBA CITY
Mailing Address - State:CA
Mailing Address - Zip Code:95991-4217
Mailing Address - Country:US
Mailing Address - Phone:530-674-4261
Mailing Address - Fax:530-674-4269
Practice Address - Street 1:935 MARKET ST
Practice Address - Street 2:
Practice Address - City:YUBA CITY
Practice Address - State:CA
Practice Address - Zip Code:95991-4217
Practice Address - Country:US
Practice Address - Phone:530-674-4261
Practice Address - Fax:530-674-4269
Is Sole Proprietor?:No
Enumeration Date:2016-07-19
Last Update Date:2019-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA53445363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical