Healthcare Provider Details

I. General information

NPI: 1922640143
Provider Name (Legal Business Name): KRISHNA VATTAMPARAMBIL PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/09/2019
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3349 NE 33RD ST STE B
FORT LAUDERDALE FL
33308
US

IV. Provider business mailing address

3349 NE 33RD ST STE B
FORT LAUDERDALE FL
33308-7111
US

V. Phone/Fax

Practice location:
  • Phone: 954-909-4998
  • Fax:
Mailing address:
  • Phone: 954-909-4998
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9111159
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: