Healthcare Provider Details

I. General information

NPI: 1972176832
Provider Name (Legal Business Name): DR. PADMAVATHI MOGILI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/20/2021
Last Update Date: 06/03/2026
Certification Date: 06/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

820 E 17TH ST
CHEYENNE WY
82001-4714
US

IV. Provider business mailing address

820 E 17TH ST
CHEYENNE WY
82001-4714
US

V. Phone/Fax

Practice location:
  • Phone: 307-632-2434
  • Fax:
Mailing address:
  • Phone: 307-632-2434
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA14774
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License NumberPA14774
License Number StateTX
# 4
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateWY
# 5
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110-008764
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: