Healthcare Provider Details

I. General information

NPI: 1528849882
Provider Name (Legal Business Name): SRISAI SARATDYUTI TENJERLA PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/11/2023
Last Update Date: 01/21/2025
Certification Date: 01/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2635 LAWNDALE DR
GREENSBORO NC
27408-4802
US

IV. Provider business mailing address

PO BOX 601843
CHARLOTTE NC
28260-1843
US

V. Phone/Fax

Practice location:
  • Phone: 336-867-4310
  • Fax: 336-867-4311
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0010-13813
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: