Provider Demographics
NPI:1952876427
Name:RAGHUR, SRILATHA (PA-C)
Entity Type:Individual
Prefix:
First Name:SRILATHA
Middle Name:
Last Name:RAGHUR
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 1:2616 LEGENDS WAY
Mailing Address - Street 2:
Mailing Address - City:CRESTVIEW HILLS
Mailing Address - State:KY
Mailing Address - Zip Code:41017-2418
Mailing Address - Country:US
Mailing Address - Phone:859-331-3100
Mailing Address - Fax:859-331-9147
Practice Address - Street 1:2616 LEGENDS WAY
Practice Address - Street 2:
Practice Address - City:CRESTVIEW HILLS
Practice Address - State:KY
Practice Address - Zip Code:41017-2418
Practice Address - Country:US
Practice Address - Phone:859-331-3100
Practice Address - Fax:859-331-9147
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-10
Last Update Date:2021-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3908363A00000X
KYTC763363A00000X
IN10003177A363A00000X
KYPA2423363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS05033505Medicaid
TN6197540OtherBCBS