Provider Demographics
NPI:1053952531
Name:SUNIL, LETHA MENON (PA - C)
Entity type:Individual
Prefix:MS
First Name:LETHA
Middle Name:MENON
Last Name:SUNIL
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 1:15209 GRAVENSTEIN WAY
Mailing Address - Street 2:
Mailing Address - City:NORTH POTOMAC
Mailing Address - State:MD
Mailing Address - Zip Code:20878-4701
Mailing Address - Country:US
Mailing Address - Phone:301-706-5092
Mailing Address - Fax:
Practice Address - Street 1:18101 PRINCE PHILIP DR
Practice Address - Street 2:
Practice Address - City:OLNEY
Practice Address - State:MD
Practice Address - Zip Code:20832-1514
Practice Address - Country:US
Practice Address - Phone:301-774-8882
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-04
Last Update Date:2019-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC07365363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant