Healthcare Provider Details

I. General information

NPI: 1174458780
Provider Name (Legal Business Name): SRUTI NAGAM PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/15/2026
Last Update Date: 06/15/2026
Certification Date: 06/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

590 N VERMONT AVE
LOS ANGELES CA
90004-2115
US

IV. Provider business mailing address

5624 FORBES DR
NEWARK CA
94560-3684
US

V. Phone/Fax

Practice location:
  • Phone: 323-284-7998
  • Fax:
Mailing address:
  • Phone: 732-208-0177
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: