Healthcare Provider Details

I. General information

NPI: 1811851470
Provider Name (Legal Business Name): AISHWARIYA MUDUNURI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/09/2025
Last Update Date: 12/09/2025
Certification Date: 12/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

310 S MAPLE RD
ANN ARBOR MI
48103-3833
US

IV. Provider business mailing address

6185 SMITHFIELD DR
TROY MI
48085-1081
US

V. Phone/Fax

Practice location:
  • Phone: 734-794-3494
  • Fax:
Mailing address:
  • Phone: 248-878-1032
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601013544
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: