Provider Demographics
NPI:1164159950
Name:SUTHAR, MITTAL (FNP-C)
Entity Type:Individual
Prefix:
First Name:MITTAL
Middle Name:
Last Name:SUTHAR
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1864 MIDCHESTER DR
Mailing Address - Street 2:
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48324-1137
Mailing Address - Country:US
Mailing Address - Phone:313-516-9141
Mailing Address - Fax:
Practice Address - Street 1:4436 BEECHER RD
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48532-2609
Practice Address - Country:US
Practice Address - Phone:810-733-0290
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-02
Last Update Date:2022-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704269191363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily