Healthcare Provider Details

I. General information

NPI: 1124940333
Provider Name (Legal Business Name): MR. SRIVATSAV CHALLA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2026
Last Update Date: 08/21/2026
Certification Date: 08/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 E MOUNTAIN BLVD
WILKES BARRE PA
18711-0001
US

IV. Provider business mailing address

100 N ACADEMY AVE
DANVILLE PA
17822-4903
US

V. Phone/Fax

Practice location:
  • Phone: 570-808-7300
  • Fax: 570-808-2306
Mailing address:
  • Phone: 570-808-6020
  • Fax: 570-808-2306

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberMA067855
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberMA067855
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: