Healthcare Provider Details

I. General information

NPI: 1053082321
Provider Name (Legal Business Name): SAGAR SAI CHENNUPATI PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2021
Last Update Date: 06/07/2022
Certification Date: 06/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 PIN OAK LN
KEYSER WV
26726-5908
US

IV. Provider business mailing address

100 PIN OAK LN
KEYSER WV
26726-5908
US

V. Phone/Fax

Practice location:
  • Phone: 304-597-3500
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: