Healthcare Provider Details

I. General information

NPI: 1063167971
Provider Name (Legal Business Name): RAJENDRA SHRESTHA PA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/18/2022
Last Update Date: 02/18/2022
Certification Date: 02/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 ASHLAND RD APT J4
COLUMBIA SC
29210-5044
US

IV. Provider business mailing address

2400 ASHLAND RD APT J4
COLUMBIA SC
29210-5044
US

V. Phone/Fax

Practice location:
  • Phone: 985-415-3287
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: RAJENDRA SHRESTHA
Title or Position: PHYSICIAN ASSISTANT
Credential: PA
Phone: 985-415-3287