Healthcare Provider Details

I. General information

NPI: 1477904589
Provider Name (Legal Business Name): PRIYADARSHINI GANGULA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/29/2016
Last Update Date: 12/22/2020
Certification Date: 12/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 DUFF AVE
AMES IA
50010
US

IV. Provider business mailing address

1215 DUFF AVE
AMES IA
50010-5400
US

V. Phone/Fax

Practice location:
  • Phone: 515-239-6992
  • Fax:
Mailing address:
  • Phone: 515-239-4418
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number45817
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: