Provider Demographics
NPI:1952402547
Name:GUNDAPANENI, SIVA JYOTHIRMAYE (PA - C)
Entity Type:Individual
Prefix:MRS
First Name:SIVA
Middle Name:JYOTHIRMAYE
Last Name:GUNDAPANENI
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 1:22038 HYDE PARK DR
Mailing Address - Street 2:
Mailing Address - City:ASHBURN
Mailing Address - State:VA
Mailing Address - Zip Code:20147-6915
Mailing Address - Country:US
Mailing Address - Phone:571-223-2556
Mailing Address - Fax:
Practice Address - Street 1:50 IRVING ST NW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20422-0001
Practice Address - Country:US
Practice Address - Phone:202-745-8291
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2007-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0002000363AS0400X
DCPA30031363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical