Healthcare Provider Details

I. General information

NPI: 1215911573
Provider Name (Legal Business Name): RAMA BHYRAVABHOTLA PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/01/2005
Last Update Date: 11/23/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

325 MDOS/SGOMF 340 MAGNOLIA CIRCLE
TYNDALL AFB FL
32403
US

IV. Provider business mailing address

27 05 EAGLE DRIVE
TYNDALL AFB FL
32403-5604
US

V. Phone/Fax

Practice location:
  • Phone: 850-283-7589
  • Fax: 850-283-7129
Mailing address:
  • Phone: 850-283-7589
  • Fax: 850-283-7129

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: