Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207RR0500X | Rheumatology | 04-33130 | KS |
NPI | 1114107182 |
---|---|
Provider Name | Dr. Praveena Gorantla |
First Address | Winfield, KS 67156-3144 |
Second Address | Winfield, KS 67156-3145 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 07/11/2007 |
Last Update Date | 22/04/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
200569320A | (05) | KS |
P01144793 | RR MEDICARE (01) |