Provider Demographics
NPI:1811470248
Name:VAITLA, KRISHNA SUMAN (PT, MSRS, DPT)
Entity type:Individual
Prefix:
First Name:KRISHNA SUMAN
Middle Name:
Last Name:VAITLA
Suffix:
Gender:M
Credentials:PT, MSRS, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:705 TRANCAS ST
Mailing Address - Street 2:
Mailing Address - City:NAPA
Mailing Address - State:CA
Mailing Address - Zip Code:94558-3014
Mailing Address - Country:US
Mailing Address - Phone:707-255-6060
Mailing Address - Fax:
Practice Address - Street 1:705 TRANCAS ST
Practice Address - Street 2:
Practice Address - City:NAPA
Practice Address - State:CA
Practice Address - Zip Code:94558-3014
Practice Address - Country:US
Practice Address - Phone:707-255-6060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-12
Last Update Date:2018-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501014706225100000X
IN05010039A225100000X
CA41246225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist