Provider Demographics
NPI:1003211046
Name:PATEL PRABHU, NISHA ASHOK (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:NISHA
Middle Name:ASHOK
Last Name:PATEL PRABHU
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 1:601 VERSAILLES RD
Mailing Address - Street 2:
Mailing Address - City:FRANKFORT
Mailing Address - State:KY
Mailing Address - Zip Code:40601-3857
Mailing Address - Country:US
Mailing Address - Phone:502-695-3946
Mailing Address - Fax:
Practice Address - Street 1:601 VERSAILLES RD
Practice Address - Street 2:
Practice Address - City:FRANKFORT
Practice Address - State:KY
Practice Address - Zip Code:40601-3857
Practice Address - Country:US
Practice Address - Phone:502-695-3946
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-04
Last Update Date:2014-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYTC340363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY61-1358646OtherFEDERAL TAX NUMBER