Provider Demographics
NPI:1497282610
Name:GUNASENA, ACHALA SHIVANTHI (PA-C)
Entity type:Individual
Prefix:
First Name:ACHALA
Middle Name:SHIVANTHI
Last Name:GUNASENA
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 1:400 W 7TH ST
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21701-4506
Mailing Address - Country:US
Mailing Address - Phone:240-215-6310
Mailing Address - Fax:
Practice Address - Street 1:7211 BANK CT
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21703-8483
Practice Address - Country:US
Practice Address - Phone:240-215-6310
Practice Address - Fax:240-566-7754
Is Sole Proprietor?:No
Enumeration Date:2017-05-18
Last Update Date:2024-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0006440363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant