Healthcare Provider Details

I. General information

NPI: 1477676286
Provider Name (Legal Business Name): PANCHALI KHANNA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/08/2007
Last Update Date: 06/09/2020
Certification Date: 06/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1243 E SPRUCE AVE STE 104
FRESNO CA
93720-3379
US

IV. Provider business mailing address

1243 E SPRUCE AVE STE 104
FRESNO CA
93720-3379
US

V. Phone/Fax

Practice location:
  • Phone: 559-554-9442
  • Fax: 559-293-4969
Mailing address:
  • Phone: 559-554-9442
  • Fax: 559-293-4969

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number4301083133
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License NumberA112116
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: