Provider Demographics
NPI:1053714543
Name:KANURI, SOWJANYA (PA-C)
Entity type:Individual
Prefix:
First Name:SOWJANYA
Middle Name:
Last Name:KANURI
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:812 GREEN HOLLOW DR
Mailing Address - Street 2:
Mailing Address - City:ISELIN
Mailing Address - State:NJ
Mailing Address - Zip Code:08830-2932
Mailing Address - Country:US
Mailing Address - Phone:401-954-1216
Mailing Address - Fax:
Practice Address - Street 1:812 GREEN HOLLOW DR
Practice Address - Street 2:
Practice Address - City:ISELIN
Practice Address - State:NJ
Practice Address - Zip Code:08830-2932
Practice Address - Country:US
Practice Address - Phone:401-954-1216
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-29
Last Update Date:2014-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00346600363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical