Healthcare Provider Details

I. General information

NPI: 1558760124
Provider Name (Legal Business Name): SRIVATSA CHIHNA KOWSIKA PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2014
Last Update Date: 01/13/2025
Certification Date: 01/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4755 OGLETOWN STANTON RD STE 5A43
NEWARK DE
19718-2200
US

IV. Provider business mailing address

15059 N SCOTTSDALE RD STE 600
SCOTTSDALE AZ
85254-2685
US

V. Phone/Fax

Practice location:
  • Phone: 302-623-0188
  • Fax: 302-733-5640
Mailing address:
  • Phone: 602-778-3601
  • Fax: 928-432-7001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601007070
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberC0009591
License Number StateMD
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberC5-0001060
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: