MEDICARE: SUNAINA DEVI RAVURU PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	027199	OTHER	NY	STATE LICENSE

General Provider Information

NPI Number	:	1699346775
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUNAINA DEVI RAVURU PA

Provider Business Mailing Address
First Line	:	11616 LIBERTY AVE
Second Line	:
City	:	SOUTH RICHMOND HILL
State	:	NY
Zip	:	11419-1941
Country	:	US
Telephone Number	:	718-641-1117
Fax Number	:

Provider Business Practice Location Address
First Line	:	11616 LIBERTY AVE
Second Line	:
City	:	SOUTH RICHMOND HILL
State	:	NY
Zip	:	11419-1941
Country	:	US
Telephone Number	:	718-641-1117
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/08/2021
Last Update Date	:	10/02/2021

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