Provider Demographics
NPI:1174102883
Name:MEMULA, POOJITHA MALLI GOUD (PA)
Entity type:Individual
Prefix:
First Name:POOJITHA
Middle Name:MALLI GOUD
Last Name:MEMULA
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MS
Other - First Name:POOJITHA
Other - Middle Name:MALLI GOUD
Other - Last Name:MEMULA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:POOJA MEMULA
Mailing Address - Street 1:1750 CAMDEN RD APT 520
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28203-6571
Mailing Address - Country:US
Mailing Address - Phone:803-292-5335
Mailing Address - Fax:
Practice Address - Street 1:1750 CAMDEN RD APT 520
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28203-6571
Practice Address - Country:US
Practice Address - Phone:803-292-5335
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-08
Last Update Date:2023-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant