Provider Demographics
NPI:1083175236
Name:PATEL, NISHA (PA)
Entity Type:Individual
Prefix:
First Name:NISHA
Middle Name:
Last Name:PATEL
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2902 59TH ST W STE C
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34209-7021
Mailing Address - Country:US
Mailing Address - Phone:248-659-2718
Mailing Address - Fax:941-444-4156
Practice Address - Street 1:2902 59TH ST W STE C
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34209-7021
Practice Address - Country:US
Practice Address - Phone:248-659-2718
Practice Address - Fax:941-444-4156
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-29
Last Update Date:2019-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9111830363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP340637-93-629-0OtherDRIVE'S LIC