Provider Demographics
NPI:1881247393
Name:VAIDYANATHAN, ANITA (PA-C)
Entity type:Individual
Prefix:
First Name:ANITA
Middle Name:
Last Name:VAIDYANATHAN
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 1:12665 VILLAGE LN APT 4507
Mailing Address - Street 2:
Mailing Address - City:PLAYA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:90094-2863
Mailing Address - Country:US
Mailing Address - Phone:949-201-9955
Mailing Address - Fax:
Practice Address - Street 1:12665 VILLAGE LN APT 4507
Practice Address - Street 2:
Practice Address - City:PLAYA VISTA
Practice Address - State:CA
Practice Address - Zip Code:90094-2863
Practice Address - Country:US
Practice Address - Phone:949-201-9955
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-23
Last Update Date:2019-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant