Healthcare Provider Details

I. General information

NPI: 1477735272
Provider Name (Legal Business Name): KISHORE SHM VARADA PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/04/2007
Last Update Date: 12/04/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1445 SPAULDING AVE
RICHLAND WA
99352
US

IV. Provider business mailing address

367 ROCKWOOD DRIVE
RICHLAND WA
99352
US

V. Phone/Fax

Practice location:
  • Phone: 509-420-0423
  • Fax: 509-627-2090
Mailing address:
  • Phone: 509-539-4273
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA10005331
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: