MEDICARE: KRISHNA VATTAMPARAMBIL PA-C

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	PA9111159	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	PA9111159	OTHER	FL	FLORIDA DEPARTMENT OF HEALTH

General Provider Information

NPI Number	:	1922640143
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KRISHNA VATTAMPARAMBIL PA-C

Provider Business Mailing Address
First Line	:	3349 NE 33RD ST STE B
Second Line	:
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33308-7111
Country	:	US
Telephone Number	:	954-909-4998
Fax Number	:

Provider Business Practice Location Address
First Line	:	3349 NE 33RD ST STE B
Second Line	:
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33308
Country	:	US
Telephone Number	:	954-909-4998
Fax Number	:

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

Provider Enumeration Date	:	10/09/2019
Last Update Date	:	03/07/2023

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