Healthcare Provider Details

I. General information

NPI: 1952876427
Provider Name (Legal Business Name): SRILATHA RAGHUR PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/10/2018
Last Update Date: 09/10/2026
Certification Date: 09/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8000 5 MILE RD
CINCINNATI OH
45230-2163
US

IV. Provider business mailing address

2616 LEGENDS WAY
CRESTVIEW HILLS KY
41017-2418
US

V. Phone/Fax

Practice location:
  • Phone: 513-624-4558
  • Fax:
Mailing address:
  • Phone: 859-331-3100
  • Fax: 859-331-9147

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA2423
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberTC763
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10003177A
License Number StateIN
# 4
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number3908
License Number StateTN
# 5
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: