Healthcare Provider Details

I. General information

NPI: 1861601437
Provider Name (Legal Business Name): SUKUMARN SARAH MINGVIRIYA MSHS, PA-C, ATRET
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/21/2007
Last Update Date: 01/03/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

39400 PASEO PADRE PKWY
FREMONT CA
94538-2310
US

IV. Provider business mailing address

41492 ALICE ST
FREMONT CA
94539-4533
US

V. Phone/Fax

Practice location:
  • Phone: 510-248-3000
  • Fax:
Mailing address:
  • Phone: 510-396-5134
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number015283
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number53437
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: