Healthcare Provider Details

I. General information

NPI: 1467957324
Provider Name (Legal Business Name): SUPRAJA THUNUGUNTLA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2018
Last Update Date: 06/17/2026
Certification Date: 06/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 28TH ST S FL 2
GREAT FALLS MT
59405-5296
US

IV. Provider business mailing address

PO BOX 6010
GREAT FALLS MT
59406-6010
US

V. Phone/Fax

Practice location:
  • Phone: 406-455-4320
  • Fax: 406-731-8318
Mailing address:
  • Phone: 406-731-8817
  • Fax: 406-731-8318

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License Number173110
License Number StateMT
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: