Individual
SRIVIDYA THOTAKURA
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
PAC
Contact information
Practice address
13158 RUBY LACE CT, HERNDON, VA 20171-2337
(612) 200-4585
Mailing address
13158 RUBY LACE CT, HERNDON, VA 20171-2337
(612) 200-4585
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
—
—
Other
Enumeration date
11/16/2015
Last updated
11/16/2015
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