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General NPI Number Information
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NPI Number | 1750432142
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Entity Type | Individual
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Provider Name | VIDYA NANDINI BALKISHUN PA-C
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Gender | Female
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Dates
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Enumeration Date | 01/15/2007
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Last Update Date | 10/21/2024
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Provider Practice Location Address
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Address Line | 18947 JOHN J WILLIAMS HWY UNIT 101
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City | REHOBOTH BEACH
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State | DE
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Zip | 19971-4480
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Country | US
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Telephone | 302-645-3770
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Fax | 302-645-5718
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Provider Business Mailing Address
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Address Line | 1915 WHITE AVE
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City | KNOXVILLE
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State | TN
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Zip | 37916-2300
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Country | US
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Telephone | 865-331-1720
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | MA051675
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License Number State | PA
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Taxonomy #2
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | 4813
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License Number State | TN
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Taxonomy #3
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | C5-0012102
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License Number State | DE
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